Health Assessment and Management Questionnaires

Health Assessment Questionnaire
Health Management Questionnaire

Health Assessment Questionnaire

About You - Step 1 of 7

1. About You

Please complete all fields.

Name *

First

Last

Age *

Height *

Height in Meters

Weight *

Weight in Kg

Waist *

Waist Size in Centimeters

Family History of Cardio Vascular Disease(s)

Is there a family history of any of the following: Heart and circulatory disease, heart attack, heart failure, atrial fibrillation, stroke? (immediate family members i.e Grandparents, parents, brothers, sisters)

Any Other Hereditary Conditions

2. Lifestyle and Physical Activity Levels

Please complete all fields.

How many times per week do you exercise? *

Once
More Than Twice
Over 3 Times

How long do you exercise for? *

1hr or less per week
Up to 2hrs per week
Over 3hrs per week

How much brisk walking do you do per day? *

None
Under an hour
Up to 2hrs
2hrs or more

Are you a smoker *

No
Yes
Given up smoking

Do you smoke frequently? *

How many do you smoke a day *

Please indicate how many

How many do you smoke per week *

Please indicate how many

How much alcohol do you drink on average per week in units? *

1 unit is equivalent to 1 small glass of wine, ½ a pint of beer or lager or a shot of spirit

3. Your Diet

Please complete all fields

Dietary Intake *

Do you estimate that you eat 5 portions of fruit and vegetables per day? *

How many portions? *

Do you have a special diet? *

Please give details of your special diet. *

4. Your Personal Health

Do you suffer from *

Thyroid
Diabetes
Arthritis
Asthma
Depression
Other health conditions
None

Please give as much details as possible

Have you ever had raised Cholesterol? *

No
Yes
Not sure

Are you being treated for this? *

What medication are you currently taking for your Cholesterol? *

Are you taking medication for anything else? *

What other medication(s) are you currently taking? *

Please list and seperate each item with a comma

5. Your Goals

What would you like to achieve? *

What small thing(s) can you commit to changing? *

E.g: Reduce my weight.

How will you measure your success? *

E.g: By weight loss measured each week.

What do you think will get in the way of achieving this? *

E.g Mindset, working late, being tired, poor diet.

How can you stop this happening? *

E.g: Schedule my week to plan exercises for 30 minutes to 60 minutes in my diary.

How can we help and support you?

What additional goals do you have for yourself?

6. Your Clinical Assessment

Skip This Step. To be carried out by the Health Care or Clinical Practitioner.

Blood Pressure (Left Arm)

Blood Pressure (Right Arm)

Pulse

Heart Rate

Total Cholesterol

< 5 Low risk | 5.0 - 7.4 Increased risk | 7.5+ High Risk

HDL (Good Cholesterol)

Low risk ( M) 1.0 | Low risk (F) 1.2+

7. Your Consent and Feedback

Would you like to be informed about ongoing health management services? *

Your Email *

Confirm Email

Please provide a working email if you have indicated that we contact you about ongoing services.

How did you hear about us? *

Please indicate where you heard about us or our services.

Where did you hear about us?

Helps us better understand how to reach and help more people

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Captcha *

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Website

Health Management Club

About You - Step 1 of 6

1. About You

Name *

First

Last

Age *

Height *

Height in Meters

Weight *

Weight in Kg

Waist *

Waist Size in Centimeters

Family History of Cardio Vascular Disease(s)

Please give the current age and state of health of the following relatives, or if deceased, their age and the cause of death Is there a family history of any of the following (Grandparents, parents, brothers, sisters)? If appropriate please provide details.

Any Other Hereditary Conditions

2. Lifestyle and Physical Activity Levels

How many times per week do you exercise? *

Once
More Than Twice
Over 3 Times

How long do you exercise for? *

1hr or less per week
Up to 2hrs per week
Over 3hrs per week

How much brisk walking do you do per day? *

None
Under an hour
Up to 2hrs
2hrs or more

Are you a smoker *

No
Yes
Given up smoking

Do you smoke frequently? *

How many do you smoke a day *

Please indicate how many

How many do you smoke per week *

Please indicate how many

How much alcohol do you drink on average per week in units? *

1 unit is equivalent to 1 small glass of wine, ½ a pint of beer or lager or a shot of spirit

3. Your Diet

Dietary Intake *

Do you estimate that you eat 5 portions of fruit and vegetables per day? *

How many portions? *

Do you have a special diet? *

Please give details of your special diet. *

4. Your Personal Health

Do you suffer from *

Thyroid
Diabetes
Arthritis
Asthma
Depression
Other health conditions

Please give as much details as possible

Have you ever had raised Cholesterol? *

No
Yes
Not sure

Are you being treated for this? *

What medication are you currently taking for your Cholesterol? *

Are you taking medication for anything else? *

What other medication(s) are you currently taking? *

Please list and seperate each item with a comma

5. Your Goals

What would you like to achieve? *

What small thing(s) can you commit to changing? *

How will you measure your success? *

What do you think will get in the way of achieving this? *

How can you stop this happening? *

How can we help and support you?

What additional goals do you have for yourself?

6. Your Consent & Feedback

How did you hear about us? *

Please indicate where you heard about us or our services

Your Email *

Confirm Email

Please provide a working Email

Opt-In to receive our newsletter.

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Captcha *

What is 7+4?