Welcome to the nutrition consultation pre-survey

Please complete the Nutrition survey below. Your results will be emailed to you.

Bodycare | Healthworks

PERSONAL DETAILS

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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 nutrition consultation is voluntary.


  • I acknowledge that any personally identifiable health information obtained in conjunction with this nutrition consultation 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 scores on 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 survey 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 sleep consultation as part of an aggregate result to the relevant department of my employer.
    Consent
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    NUTRITION CONSULTATION

    Are you eating for health? Please answer the below questions, based on an average day or an average week for you.

    On average, 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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    On average, how many serves of vegetables do you eat per day?
    A serve is ½ cup cooked vegetables (hot chips don’t count!) or 1 cup of salad.
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    How often do you choose wholegrains?
    Such as high fibre breakfast cereal, wholemeal bread, brown rice, brown pasta
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    On average, how many serves of dairy or dairy alternatives do you eat per day?
    1 serve = glass 250ml of milk or calcium enriched alternative milk, 200g tub yoghurt , 40g cheese
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    On average, how many serves of lean meat or chicken, fish, eggs, nuts or legumes do you consume each day?
    1 serve = lean skinless poultry or lean red meat (approx. 100g), fish and seafood (approx. 200g), eggs (2), legumes (approx. 100g) or tofu (approx. 100g), nuts (20g)
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    On average, how much water do you drink every day? (including herbal tea)
    Limit drinks with added sugars include soft drinks, cordial, energy drinks and sports drinks.
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    On average, how often do you eat takeaway foods each week?
    These are takeaways such as pizzas, burgers, chips or other fried foods
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    On average, how often do you eat store-bought cakes, muffins, chocolate, ice cream, pastries, pies & biscuits each week?
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    Do you limit salty foods to once a week or less, & avoid adding salt during cooking or at the table?
    These include processed meats such as salami & bacon, crisps,& salty snacks.
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    On average, how many alcoholic beverages do you consume each week?
    1 standard drink = 1000mL wine or sparkling wine, 30mL spirit, 285 mL beer (1 x middy/pot) or 425mL low strength beer (1 x schooner)
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    Understanding Your Score

    Your Score
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    Understanding your score

    • Under 8: need serious improvements

    • 8-14: could make some improvements

    • 15-20: nutrition is on track!

    FOOD DIARY

    Provide an example of a typical work day and weekend eating and drinking habits. Be as specific as you can such as detailing the type of bread you choose, if you add sugar to your tea/coffee, what milk you use, what time you eat, the toppings on your sandwich or the vegetables in your salad. Please also include any juices, soft drinks or alcoholic beverages and make a note of water in cups or litres.

    Breakfast Weekday
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    Morning Snack Weekday
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    Lunch Weekday
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    Afternoon Snack Weekday
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    Dinner Weekday
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    Water Weekday
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    Breakfast Weekend
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    Morning Snack Weekend
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    Lunch Weekend
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    Afternoon Snack Weekend
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    Dinner Weekend
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    Water Weekend
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    When you hit the submit button, the form may take a little while to process. Please do not hit the back button or close the browser while the form is submitting.

    Do you have a specific concern you are looking to address or are you looking for general health advice in this consult?
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    Once you have completed your survey, you’ll be taken to a page where you can book in for your nutrition consultation. You’ll also receive the booking link in your completed questionnaire email.