RBA – qEEG.co.uk

Breathing has a large effect on heart rate variability (HRV) but these questions are about some other factors that are also known to affect the HRV; Age, Sex, Circadian rhythm (i.e., time of day) and sleep, Menstrual cycle, diabetes, Fitness, BMI and whether you smoke, and alcohol consumption, and even when you last had caffeine. (We will ask some of these question on the day you come to the in person sessions)

Remember you don't have to answer any questions you don't want to!

ID or Name:

E-Mail (If you want your results emailed to you):

Age: How old are you?

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75-84

85 or over

Sex?

Female Intersex Male

What is your weight?

Underweight - (BMI under 18.5)

Healthy Range - (BMI between 18.5 and 24.9)

Overweight - (BMI between 25 and 29.9)

Obesity - (BMI between 30 and 39.9)

During the last 12 months, how often did you usually have any kind of drink containing alcohol?

By a drink we mean 15 millilitres (half an ounce) of absolute alcohol (e.g., 350 millilitres (12-ounce) can or glass of beer or cooler, a 150 millilitres (5 ounce) glass of wine, or a drink containing 1 shot of liquor).

Every day

5 to 6 times a week

3 to 4 times a week

twice a week

once a week

2 to 3 times a month

once a month

3 to 11 times in the past year

1 or 2 times in the past year

I did not drink any alcohol in the past year, but I did drink in the past (skip the next two questions)

I never drank (skip the next two questions)

During the last 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol?

25 or more drinks

19 to 24 drinks

16 to 18 drinks

12 to 15 drinks

9 to 11 drinks

7 to 8 drinks

5 to 6 drinks

3 to 4 drinks

2 drinks

1 drink

During the last 12 months, how often did you have 5 or more (males) or 4 or more (females) drinks containing any kind of alcohol in within a two-hour period?

That would be the equivalent of at least 5 (4) 350 millilitres (12-ounce) cans or bottles of beer, 5 (4) 150 millilitres (5 ounce) glasses of wine, 5 (4) drinks each containing one shot of liquor or spirits:

Every day

5 to 6 days a week

3 to 4 days a week

two days a week

one day a week

2 to 3 days a month

one day a month

3 to 11 days in the past year

1 or 2 days in the past year

Never

Which item best describes your smoking?

1. Heavy smoker: I smoke a pack or more a day (or more than 200 puffs of an E-Cigs)

2. Moderate smoker: I smoke between 10 to 20 cigarettes a day

3. Light smoker: I smoke less than 10 cigarettes per day

4. Occasional smoker: either not smoking every day or smoking an average of less than one cigarette a day

5. Not anymore: I quit more than 1 year ago but was a Heavy smoker

6. Not anymore: I quit more than 1 year ago but was a Moderate smoker

7. Not anymore: I quit more than 1 year ago but was a Light smoker

8. Non-Smoker: I never smoker or maybe tried it once or twice

How long have you been a smoker? (In number of years, i.e., "3" or "1.5")

Do you have any comments about your smoking?

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