Bodycare | Healthworks

Personal Details

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Gender (optional)
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Please select the date for which you booked your coaching session.
Please select the date for which you booked your coaching session.
RELEASE OF INFORMATION AND PARTICIPATION CONSENT
Participant Release of Information Consent pursuant to Federal Privacy Act 1988 (AU) or Privacy Act 1993 (NZ)



  • I confirm that my participation in this coaching session is voluntary.

  • I acknowledge that any personally identifiable health information obtained in conjunction with this coaching session will be protected and will only be used in accordance with this agreement and applicable laws pertaining to the use of personal health information.


  • I understand that any health information obtained, may be used to compile a deidentified aggregate report for my company/employer. While my employer may be notified of my participation, my individually identifiable health information will not be shared with my employer.

  • I understand that the following self-assessment do not reflect any particular diagnosis or course of treatment. The data collected does not constitute a diagnosis. The responsibility for initiating a follow-up assessment to confirm the results of this questionnaire and obtain professional assistance is mine alone and not that of my employer or any organisation associated with this survey.

  • I hereby give Bodycare Health & Wellbeing Pty Ltd consent to release the de-identified results of my questionnaire as part of an aggregate result to my employer.
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    Consent
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    Nutrition

    1. How many serves of fruit do you eat per day?
    A serve is 1 medium piece or 2 small pieces of fresh fruit, or 1 cup of chopped or canned fruit (no added sugar).
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    2. How many serves of vegetables do you eat each day?
    A serve is ½ cup cooked vegetables (hot chips don’t count!) or 1 cup of salad.
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    3. How many times per week do you consume food or drinks containing added sugar?
    eg chocolate, ice cream, muffins or baked goods, cake, biscuits, soft drinks, sports drinks, energy drinks, fruit juices, added sugar in tea or coffee.
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    4. How many times per week do you eat out or order takeaway foods?
    This includes breakfast, lunch and dinner during the week and on weekends.
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    5. How many glasses of water do you drink each day?
    1 glass = 250ml
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    6. On a scale of 1–10, how would you rate your current eating habits?
    Where 1 = Needs serious improvements and 10 = Excellent
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    7. Why have you chosen this score?
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    Exercise

    1. How many times per week do you usually exercise?
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    2. How long is a usual exercise session for you? (in mins)
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    3. List the types of exercise you normally do:
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    4. Approximately how many hours do you spend sitting each day?
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    5. On average, do you take a movement break from sitting every 60 mins?
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    6. On a scale of 1–10, how would you rate your current exercise habits?
    Where 1 = Needs serious improvements and 10 = Excellent
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    7. Why have you chosen this score?
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    Sleep

    1. How many hours of sleep do you get each night?
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    2. Do you have a consistent night time routine?
    eg go to bed at the same time, have a wind down routine that you do most nights
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    3. How long does it take you to fall asleep at night?
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    4. Do you snore?
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    5. Do you feel rested and refreshed in the morning?
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    6. Do you perform shift work?
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    7. Do you nap during the day?
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    8. How many caffeinated drinks do you have each day?
    eg tea, coffee, energy drinks
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    9. On a scale of 1–10, how would you rate your current sleep habits?
    Where 1 = Needs serious improvements and 10 = Excellent
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    10. Why have you chosen this score?
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    General Health

    1. Do you smoke?
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    2. On average, would you drink more than 10 standard drinks per week?
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    3. How often would you drink more than 4 standard drinks on any day?
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    4. Do you have a regular GP?
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    5. Do you have any current medical conditions?
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    6. On a scale of 1–10, how would you rate your general health?
    Where 1 = Needs serious improvements and 10 = Excellent
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    7. Why have you chosen this score?
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    Health Goal

    Which of these goals is your top priority for this coaching session?
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    What would you like to improve about your general health?
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