DFES Health Assessment Questionnaire "*" indicates required fields Step 1 of 6 16% Personal DetailsName* First Last Date of Birth* DD slash MM slash YYYY Contact Number*Email* Employment DetailsCompany* Position Work Email Work PhoneEmergency Contact DetailsName* First Last Phone* Medical HistoryFamily HistoryPlease select all that apply Alzheimer’s Disease High Blood Pressure Elevated cholesterol Cardiovascular Disease Stroke Heart Attack Depression / Anxiety Diabetes Type I Diabetes Type II Inflammatory Bowel Disease Multiple Sclerosis Lupus Rheumatoid Arthritis Obesity Haemachromatosis Leukemia/Lymphoma Breast Cancer Colorectal/Bowel Cancer Ovarian Cancer Prostate Cancer Lung Cancer Other Cancer Melanoma Glaucoma Kidney Disease Osteoporosis Asthma Other OtherPlease specify Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?* Yes No Where were you born?*Please select one Australia North or South America Asia (including the Indian sub-continent) Africa Europe Other OtherPlease specify Personal HistoryHave you ever experienced or been diagnosed with any of the following? High Blood Pressure Elevated cholesterol Extra heart beats or skipped beats Abnormal ECG Heart Attack Coronary Heart Disease Stroke High blood glucose reading Diabetes Type I Diabetes Type II Difficulty breathing Frequent cramps in your legs Varicose Veins Blood clots or Deep vein thrombosis Dizziness or fainting spells Epilepsy Anxiety Depression Breast Cancer Colon Cancer Prostate Cancer Chronic Fatigue Benign Prostate enlargement Bronchitis / Chronic Bronchitis Sleep Disorders Being out of breath while sitting or sleeping Rheumatoid Arthritis Low Iron Stores (Anaemia) High Iron Stores Thyroid Problems Migraines or Headaches Chronic or recurring morning cough Kidney Stones Difficulty with urination i.e. pain, poor flow Rectal bleeding Gout Stomach of Intestinal problems i.e. recurrent heart burn, ulcers, constipation or diarrhea Inflammatory Bowel Disease Irritable Bowel Syndrome Difficulties with hearing Difficulties with vision Fibromyalgia Hayfever Menopause Osteoarthritis Back Pain Osteoporosis Other OtherPlease specify Examination HistoryDate of last physical examination Please outline any other medical or diagnostic tests you have received in the past two years:Pease list any allergies you are aware of: Prescription MedicationDo you take any prescription medication for the following? High Blood Pressure Cholesterol Diabetes Name/type of medication Please list any other prescription or self-prescribed medications or dietary supplements you are currently taking and the condition they are for: For the purpose of reproductive health, how do you identify?MaleFemalePrefer Not to AnswerMale Reproductive HealthDo you have a regular prostate examination? Yes No Do you have regular testicular examinations?Self-check or by medical professional Yes No Have you noticed any lumps in the groin or testicles? Yes No Do you have any concerns regarding your reproductive health?Please specify if applicable Female Reproductive HealthDo you experience any menstrual or period problems? Yes No Have you experience any significant childbirth problems? Yes No N/A Do you regularly examine your breasts?Self-check or by a medical professional Yes No Do you have a regular mammogram? Yes No Do you sometimes lose urine when you cough, sneeze or laugh? Yes No Do you have any concerns regarding your reproductive health?Please specify if applicable LifestylePhysical ActivityHow much physical activity do you do outside of work?Sedentary (>1hr per week)Occasionally active (1-2hrs per week)Moderately active (2.5-4hrs per week)Very active (>5hrs per week)What physical activities do you participate in? Alcohol ConsumptionWhat is your average alcohol consumption?(standard drinks/day)Nil/Non-Drinker1 - 23 - 45 - 6More than 6Alcohol free days per week? Zero 1 - 2 3 - 4 5 - 7 Which best describes your smoking status?Non-smokerPrevious smoker <6 monthsPrevious smoker >6 monthsSocial smokerRegular smokerVaperCaffeine consumptionHow many serves a day? i.e. coffee, tea, energy drinks and soft drinks0 serves/day1 - 2 serves/day3 - 4 serves/day> 4 serves/dayDietPer day, how often do you consume the following:WaterGlasses per day< 2 per day2 - 4 per day4 - 6 per day6 - 8 per day> 8 per dayProtein - Meat and legumes(peas, beans, chickpeas, etc.)Rarely / NeverSome MealsMost MealsEvery MealTwo serves of dairy productsRarely / Never1 - 2 days/week3 - 5 days/week6 - 7 days/weekCarbohydrates(Bread, rice, potato, pasta, cereal and grains)3 serves or less per day3 - 4 serves/day5 - 6 serves/dayEvery mealFruitZero serves/day1 serve/day2 or more serves/dayVegetablesZero serves/day1 - 2 serves/day3 - 4 serves/day5 or more serves/dayHow often do you have takeaway/fast foods?Everyday3 - 6x per week1 - 4x per weekMonthly or less Relationships and Mental HealthAre you currently married or in a long term relationship? Yes No Do you consider your partner to be a close friend with whom you can share your feelings, problems and accomplishments? Yes No Do you feel that you have friends or family who provide you with the emotional support you need? Yes No Please rate your perceived stress level in the last month*(1= low stress, 10= very high stress level)12345678910What are the main contributing factors? Work Home Money Health Relationship None of the above Please rate your current work / life balance*(1= well balanced, 10= unbalanced)12345678910DASS 21 QuestionnairePlease read each statement and select a number which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 - did not apply to me at all (never) 1 - applied to me to some degree (sometimes) 2 - applied to me a considerable degree (often) 3 - applied to me very much (almost always)I found it hard to wind down*1 = Never2 = sometimes3 = often4 = almost alwaysI was aware of dryness in my mouth*1 = Never2 = sometimes3 = often4 = almost alwaysI couldn't seem to experience any positive feelings at all*1 = Never2 = sometimes3 = often4 = almost alwaysI experienced breathing difficulties (eg: rapid breathing, breathlessness in absence of exertion)*1 = Never2 = sometimes3 = often4 = almost alwaysI found it difficult to work up the initiative to do things*1 = Never2 = sometimes3 = often4 = almost alwaysI tended to over-react to situations*1 = Never2 = sometimes3 = often4 = almost alwaysI experienced trembling (eg: in the hands)*1 = Never2 = sometimes3 = often4 = almost alwaysI felt that I was using alot of nervous energy*1 = Never2 = sometimes3 = often4 = almost alwaysI was worried about situations in which I might panic and make a fool of myself*1 = Never2 = sometimes3 = often4 = almost alwaysI felt that I had nothing to look forward to*1 = Never2 = sometimes3 = often4 = almost alwaysI found myself getting agitated*1 = Never2 = sometimes3 = often4 = almost alwaysI found it difficult to relax*1 = Never2 = sometimes3 = often4 = almost alwaysI felt down-hearted and blue*1 = Never2 = sometimes3 = often4 = almost alwaysI was intolerant of anything that kept me from getting on with what I was doing*1 = Never2 = sometimes3 = often4 = almost alwaysI felt I was close to panic*1 = Never2 = sometimes3 = often4 = almost alwaysI was unable to become enthusiastic about anything*1 = Never2 = sometimes3 = often4 = almost alwaysI felt I wasn't worth much as a person*1 = Never2 = sometimes3 = often4 = almost alwaysI felt that I was rather touchy*1 = Never2 = sometimes3 = often4 = almost alwaysI was aware of the action of my heart in the absence of physical exertion (eg: sense of heart rate increasing)*1 = Never2 = sometimes3 = often4 = almost alwaysI felt scared without any good reason*1 = Never2 = sometimes3 = often4 = almost alwaysI felt that life was meaningless*1 = Never2 = sometimes3 = often4 = almost always SleepDo you go to sleep and wake up at approximately the same time each day, 7 days a week? Yes No How many hours of sleep do you get per night (average)?3 hrs or less4 - 5 hrs6 - 8 hrs9 hrs or moreHave you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea or narcolepsy? Yes No Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep? Yes No How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you.Sitting and reading*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingWatching TV*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingSitting, inactive in a public place (i.e: movies or meeting)*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingAs a passenger, in a car for an hour without a break*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingLying down to rest in the afternoon when circumstances permit*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingSitting and talking to someone*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingSitting quietly after a lunch without alcohol*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozingIn a car, while stopped for a few minutes in the traffic*0 = Would never doze off1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozing Consent I have read the Service Information Disclaimer and Consent provided to me and I wish to participate in this program.
