PERSONAL DETAILS

Date of birth
What's your gender?
Do you have diabetes?
Do you currently take medicaton for:
PLEASE READ
(Is this relevant if the practitioner only is using the form?) All participants are asked to undertake the following health questionnaire. This is a self administered questionnaire that assesses the areas of general health, fitness and wellbeing. The questionnaire is designed to provide the registered health professional with relevant information which will be reviewed with you as part of your heart health check.
DECLARATIONS
(Delete, or do we need an appropriate dec for health checks?) I declare the information I supply as part of this application, and any documentation supporting it, is complete and correct in every detail. I am aware any false or misleading information supplied by me will result in my application being assessed as ‘professionally unsuitable for employment’. I understand I am obliged to notify my prospective employer of any circumstance which would alter the responses or information provided in this application. I understand any failure on my part to notify my prospective employer of any such change in circumstances will result in me being deemed ‘professionally unsuitable’ and denied any opportunity for employment. I understand that should I be selected for employment, if I develop any medical condition that may affect my ability to perform the inherent demands of my role, I must disclose this to my manager as soon as possible. I understand that my signature, if given below, represents complete agreement with each of the statements set out above.
RELEASE OF INFORMATION AND PARTICIPATION CONSENT
Participant Release of Information Consent pursuant to Federal Privacy Act 1988 (AU) or Privacy Act 1993 (NZ)
(correct wording?) I hereby give Bodycare Health & Wellbeing Pty Ltd consent to release the de-identified results of my health questionnaire as part of an aggregate result to the relevant department of my employer.

HEART CHECK RESULTS

Check Type

Blood Pressure

Systolic result
Diastolic result

Resting Heart Rate

Resting heart rate result

Cholesterol

Total Cholesterol result
HDL Cholesterol result
TC: HDL Ratio result
CVD Risk (%)

Blood Glucose

Blood glucose - fasting or non-fasting?
Blood glucose result (fasting)
Blood glucose result (non-fasting)
Diabetes Risk Score

Body Composition

Waist circumference (male)
Are you pregnant?
Waist circumference (female)
Height (cm)
Weight (kg)
BMI value
BMI range

Follow Up

Are you under the care of a GP?
Is a follow up required?

PRE-ASSESSMENT QUESTIONNAIRE

Physical Activity

How many hours do you spend sitting, on an average day?
How many days a week do you usually exercise for at least 30 minutes?

Sleep

Over the past week, on average how many hours of sleep did you get each night?

Diet & Nutrition

How many servings of fruit do you usually eat each day?
How many servings of vegetables do you usually eat each day?
How many servings of wholegrains do you usually eat each day?
How many days in the past week did you eat fast food?
How many days in the past week did you eat sugary or fatty snacks?
How many days in the past week did you drink sugary drinks?
How many cups of plain water do you usually drink per day?

Smoking

What is your smoking status?

Alcohol Consumption

On average, how many drinks containing alcohol do you consume each week?
On average, how many alcoholic drinks do you consume on any day?
On average, how many days would you drink alcohol per week?

Emotional Health

In the past 3 months, how often have you felt stressed?
In the past 3 months, how often have you felt depressed?
In the past 3 months, how often have you felt anxious?

PARTICIPANT DECLARATION

I hereby declare that I have understood the above questions and certify that the information that I have provided is truthful and correct.