Health Risk Assessment Questionnaire Health Risk 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 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 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 medication or dietary supplements you are currently taking and the condition they are for: 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/weekFruitZero serves/day1 serve/day2 or more serves/dayCarbohydrates(Bread, rice, potato, pasta, cereal and grains)3 serves or less per day3 - 4 serves/day5 - 6 serves/dayEvery mealVegetablesZero 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)12345678910K10 Psychological Stress QuestionnaireIn the last 4 weeks, how often did you feel tired for no reason?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel nervous?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel so nervous that nothing could calm you down?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel hopeless?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel restless or fidgety?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel so restless that you could not sit still?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel depressed?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel that everything was an effort?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel so sad that nothing could cheer you up?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the timeIn the last 4 weeks, how often did you feel worthless?*1 = None of the time2 = A little of the time3 = Some of the time4 = Most of the time5 = All of the time 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 Informed Consent for Physical Testing*After you have completed the health and lifestyle questionnaire your health professional will assess the risk factors and determine if you are able to perform all, or some of the tests included in the assessment. After reading the following, your consent is required and the form is to be signed in the presence of the health professional. Risks and Discomforts There exists the possibility of certain changes occurring during exercise. They include abnormal blood pressure, fainting, disorder of heartbeat, and in very rare instances, heart attack or death. Every effort will be made to minimise these through the preliminary examination and by observations during testing. Emergency equipment and trained personnel are available to deal with any emergencies. Benefits to be expected The results obtained from the assessments and the exercise test may assist in the diagnosis of illness. The results may also assist in evaluating what type of physical activity is suitable for you to engage in with minimal or no risk. Questions Questions about the procedures used in the assessments and / or exercise test, or in the estimation of functional capacity are encouraged. Should you have any doubts or questions, please ask for further explanation. Freedom of Consent Your permission to perform these assessments and / or exercise test is voluntary. You are free to deny consent if you so desire. I have read this form and I consent to participate in the assessments.
