Health Assessment QuestionnaireHealth Management QuestionnaireHealth Assessment QuestionnaireAbout You - Step 1 of 71. About You Please complete all fields.Name *FirstLastAge *Height *Height in MetersWeight *Weight in KgWaist *Waist Size in CentimetersFamily 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 ConditionsNext2. Lifestyle and Physical Activity LevelsPlease complete all fields.How many times per week do you exercise? *OnceMore Than TwiceOver 3 TimesHow long do you exercise for? *1hr or less per weekUp to 2hrs per weekOver 3hrs per weekHow much brisk walking do you do per day? *NoneUnder an hourUp to 2hrs2hrs or moreAre you a smoker *NoYesGiven up smokingDo you smoke frequently? *YesNoHow many do you smoke a day *Please indicate how manyHow many do you smoke per week *Please indicate how manyHow 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 spiritPreviousNext3. Your DietPlease complete all fieldsDietary Intake *Please Select OneBalanced DietCould Be BetterVery Poor DietDo you estimate that you eat 5 portions of fruit and vegetables per day? *YesNoHow many portions? *Do you have a special diet? *YesNoPlease give details of your special diet. *PreviousNext4. Your Personal HealthDo you suffer from *ThyroidDiabetesArthritisAsthmaDepressionOther health conditionsNonePlease give as much details as possibleHave you ever had raised Cholesterol? *NoYesNot sureAre you being treated for this? *NoYesWhat medication are you currently taking for your Cholesterol? *Are you taking medication for anything else? *NoYesWhat other medication(s) are you currently taking? *Please list and seperate each item with a commaPreviousNext5. Your GoalsWhat 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?PreviousNext6. Your Clinical AssessmentSkip This Step. To be carried out by the Health Care or Clinical Practitioner.Blood Pressure (Left Arm)Blood Pressure (Right Arm)PulseHeart RateTotal Cholesterol< 5 Low risk | 5.0 - 7.4 Increased risk | 7.5+ High RiskHDL (Good Cholesterol)Low risk ( M) 1.0 | Low risk (F) 1.2+PreviousSkip Step7. Your Consent and FeedbackWould you like to be informed about ongoing health management services? *YesNoYour Email *EmailConfirm EmailPlease provide a working email if you have indicated that we contact you about ongoing services.How did you hear about us? *Word of MouthPromotional EventMedia (Radio or TV)Online (Please say where)Social Media (Please say where)Other (Please say where)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 peopleSign up to receive our Bi-Monthly Newsletter.If you would like to receive discount offers, information and advice on health matters. You can opt out at any time...!Captcha * What is 7+4? PreviousCommentSubmitHealth Management ClubAbout You - Step 1 of 61. About You Name *FirstLastAge *Height *Height in MetersWeight *Weight in KgWaist *Waist Size in CentimetersFamily 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 ConditionsNext2. Lifestyle and Physical Activity LevelsHow many times per week do you exercise? *OnceMore Than TwiceOver 3 TimesHow long do you exercise for? *1hr or less per weekUp to 2hrs per weekOver 3hrs per weekHow much brisk walking do you do per day? *NoneUnder an hourUp to 2hrs2hrs or moreAre you a smoker *NoYesGiven up smokingDo you smoke frequently? *YesNoHow many do you smoke a day *Please indicate how manyHow many do you smoke per week *Please indicate how manyHow 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 spiritPreviousNext3. Your DietDietary Intake *Please Select OneBalanced DietCould Be BetterVery Poor DietDo you estimate that you eat 5 portions of fruit and vegetables per day? *YesNoHow many portions? *Do you have a special diet? *YesNoPlease give details of your special diet. *PreviousNext4. Your Personal HealthDo you suffer from *ThyroidDiabetesArthritisAsthmaDepressionOther health conditionsPlease give as much details as possibleHave you ever had raised Cholesterol? *NoYesNot sureAre you being treated for this? *NoYesWhat medication are you currently taking for your Cholesterol? *Are you taking medication for anything else? *NoYesWhat other medication(s) are you currently taking? *Please list and seperate each item with a commaPreviousNext5. Your GoalsWhat 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?PreviousNext6. Your Consent & FeedbackHow did you hear about us? *Word of MouthPromotional EventMedia (Radio or TV)Online (Please say where)Social Media (Please say where)Other (Please say where)Please indicate where you heard about us or our servicesYour Email *EmailConfirm EmailPlease provide a working EmailOpt-In to receive our newsletter.If you would like to benefit from Membership, Health Products and Services Discount offers, information and advice on health matters. You can opt out at any time...!Captcha * What is 7+4? PreviousPhoneSubmit