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PERSONAL DETAILS

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Date of Birth (required field)
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What's your birth gender?
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Are you of Aboriginal or Torres Strait Islander origin?
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Are you of Asian origin?
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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 a close-contact of a confirmed case of coronavirus.

    2. I do not have coronavirus or 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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    Consent
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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

    How many standard alcoholic beverages would you consume in an average week?
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    On average, how often would you consume 5 or more standard drinks in a day?
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    Physical Activity

    How much time do you usually spend doing moderate or vigorous activity for exercise in total each week? (This can include work related duties such as outdoor work)
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    How many times do you complete muscle strengthening exercises per week?
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    How often do you take a movement break during work hours?
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    Sleep

    On average how many hours of sleep do you get each night?
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    Diet & Nutrition

    How many serves of fruit do you eat per day?
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    How many serves of vegetables do you eat per day?
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    Do you limit intake of foods and drinks containing added sugar?
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    Do you limit intake of foods high in saturated fat?
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    Do you limit intake of foods and drinks containing added salt?
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    How many days per week do you usually have sugary drinks?
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    Understanding Your Score

    Your Nutrition Heart Health Score
    0
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    Understanding your score

    • 0-5: Needs improvement to keep your heart healthy

    • 6-9: Could make some improvements for optimal heart health

    • 10-12: Nutrition is on track for good heart health!

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    Mood

    In the past 4 weeks, about how often:

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    ...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)
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    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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