PERSONAL DETAILS

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Date of Birth
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What's your gender?
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Do you have any of the following medical conditions?
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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 Health Check is voluntary.

  • I acknowledge that any personally identifiable health information obtained in conjunction with this health check 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 consent to the collection of blood pressure, body composition data (including waist circumference, height, weight, BMI) and a blood sample for the purpose of measuring my cholesterol and glucose levels.

  • I understand that the data derived from the check is considered to be preliminary and for screening assessments only. The data collected does not constitute a diagnosis. The responsibility for initiating a follow-up examination to confirm the results of this screening and obtain professional medical assistance is mine alone and not that of my employer or any organisation associated with these health checks.

  • Additionally, as frontline health professionals we are following government advice at the moment and asking each patient about recent travel and flu symptoms. Please confirm that


    1. I have not travelled to, including transit through, any international countries as per the Australian Government’s mandate in the last 14 days.

    2. I have not been in contact with anyone with a confirmed case of coronavirus within the last 14 days.

    3. I do not have any flu symptoms such as fever, cough, sore throat, fatigue or shortness of breath.




    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.
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    CHECK TYPE

    Check Type
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    PRE-ASSESSMENT QUESTIONNAIRE

    Smoking

    What is your smoking status?
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    Alcohol Consumption

    On average, how many standard drinks do you have on week nights?
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    On average, how many standard drinks would you consume on a weekend evening or a special occasion?
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    Physical Activity

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

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

    How many cups of plain water do you usually drink per day?
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    How many servings of fruit do you usually eat each day?
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    How many servings of vegetables do you usually eat each day?
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    How many times a week do you eat a fast food meal?
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    On average, how many sugary drinks do you consume each week?
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    Stress

    Rate your stress levels over the last month:
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    Mood

    In the past 4 weeks, about how often:

    ...did you feel tired out for no good reason?
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    ...did you feel nervous?
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    ...did you feel so nervous that nothing could calm you down?
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    ...did you feel hopeless?
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    ...did you feel restless or fidgety?
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    ...did you feel so restless you could not sit still?
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    ...did you feel depressed?
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    ...did you feel that everything was an effort?
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    ...did you feel so sad that nothing could cheer you up?
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    ...did you feel worthless?
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    HEART CHECK RESULTS

    TYPE OF HEART CHECK
    (as selected on previous page)


    {Check_Type}

    Blood Pressure

    Systolic result
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    Diastolic result
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    Resting Heart Rate

    Resting heart rate result
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    Cholesterol

    Total Cholesterol result
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    HDL Cholesterol result
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    TC: HDL Ratio result
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    LDL Cholesterol result
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    Triglycerides result
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    CVD Risk (%)
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    Blood Glucose

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

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

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