Questionnaire

First Name*
Last Name*

The following questions will serve as an initial screening that will then be expanded upon (depending on your responses) with follow up conversations.

Your responses will be securely saved to your personal account every time you click the "Next" button. This enables you to complete the questionnaire in multiple sittings if required. Just bookmark this page or use the activation link in the email you received after registering your account.

Do you now have, or have you ever had, a health related issue in the following areas?
Cardiovascular - heart problems, blood pressure, circulation
- Yes
- No
- High blood pressure
- Palpitations/irregular heart beat
- Heart murmur or heart valve problems
- Angina/chest pain
- Heart attack
- Rheumatic fever
- Ankle/leg oedema (swelling)
- Fainting spell/s or light headedness
- Dizziness (room spinning)
- Varicose veins
- Venous thrombosis/blood clots
- High cholesterol
- Need to sleep with extra pillows/sitting up
- Shortness of breath (other than from exercising and being out of shape)
- Poor circulation/circulation problems
- Congenital heart condition
- Other
Please specify other Cardiovascular issues
Respiratory - lung or breathing problems
- Yes
- No
- Asthma
- Lung infections
- Coughing up blood
- Other lung problems
Please specify other Respiratory issues
Gastrointestinal - indigestion, reflux, stomach or bowel problems
- Yes
- No
- Indigestion or Reflux
- Food intolerances
- Duodenal/gastric ulcer
- Irritable bowel syndrome
- Inflammatory bowel disease
- Frequent constipation
- Frequent diarrhoea
- Blood in the stool
- Hepatitis/other liver problems
- Gall bladder problems/surgery
- Appendix surgery
- Problems with swallowing
- Mouth/tongue/gum problems
- Unusual teeth problems (other than routine dental work and cavities)
- Problems with sense of taste
- Unexplained weight loss
- Intestinal parasites
- Haemorrhoid/other perianal problems
- Other
Please specify other Gastrointestinal issues
Renal/Urinary System - kidney, bladder, prostate problems
- Yes
- No
- Kidney problems
- Kidney/bladder infections (cystitis)
- Kidney stones
- Blood in the urine
- Other
Please specify other Renal or urinary issues
Neurological - brain or nerve problems
- Yes
- No
- Stroke
- Seizures
- Problem with brain/nerve tissue
- Head injury
- Headaches (other than minor/routine)
- Migraine
- Concussion/coma
- Any areas of weakness
- Any areas of numbness
- Muscular diseases/problems
- Other neurological disorder
Please specify other Neurological issues
Musculoskeletal - back or joint problems
- Yes
- No
- Arthritis/rheumatism
- Joint problem/s
- Joint dislocation
- Significant back injury
- Sciatica/other significant back problem
- Scoliosis
- Arm problem/s
- Leg problem/s
- Osteoporosis
- Fractured bone/s
- Other
Please specify other Musculoskeletal issues
Skin - rashes, spots, cancers
- Yes
- No
- Melanoma
- Other skin cancer - SCC, BCC
- Skin rash
- Severe/repeated childhood sunburn
- Hair problems
- Excessive sweating
- Unusual body/foot odour
- Any other skin problem
Please specify other Skin problems
Psychological - anxiety, depression, stress
- Yes
- No
- Significant difficulty handling stress
- Significant fears/phobias
- Drug/alcohol problems requiring counselling/A.A./hospitalisation
- Depression/Lowered mood (sustained for more than two weeks)
- Anxiety/Feeling nervous, difficulty relaxing, on edge
- Psychiatric hospitalisation
- Significant financial/family stresses/concerns
- Sleep difficulty/disturbance
- Other
Please specify other Psychological issues
Metabolic/Endocrine - diabetes, hormone problems
- Yes
- No
- Diabetes
- Excessive thirst
- Frequent urination
- Low blood sugar (hypoglycaemia)
- Thyroid problems
- Other
Please specify other Metabolic/Endocrine problems

Other Relevant Information
Last full medical checkup
Last dental checkup

Men
- Prostate problems/difficulty starting stream/dribbling/getting up at night to pass urine
- Testicular lumps
- Penile discharge
- Pain passing urine
- Impotence/difficulty with erection
Last prostate check (digital)

Women
- Breast lumps/discharge/other breast problems
- Hormone/menopause problems
- Significant gynaecological problems (vaginal, uterine, menstrual, ovarian)
- Other
Please specify other gynaecological or breast problems
Last Pap smear
Result
Last Breast check
Result
Last Mammogram (if over age 50)
Result

Allergies or significant sensitivities
- Medications
- Foods
- Insect or bees
Please list your medication allergies
Please list your food allergies
Please list your insect or bee allergies
Please describe your reaction if allergic or sensitive

Immunisations
Did you complete childhood immunisations?
- Yes
- No
- Don't know
Recent vaccinations
- Tetanus vaccination within 10 years
- Influenza vaccination within 1 year
- Pneumococcal vaccination
- Other vaccinations
Other vaccines

Father's Details
Is your father still alive?
- Yes
- No
- Don't know
Age
Current health
Age at death
Cause of death, health issues

Mother's Details
Is your mother still alive?
- Yes
- No
- Don't know
Age
Current health
Age at death
Cause of death, health issues

List details of your siblings:
Age Current health If deceased - age at death Cause of death, health issues
List details of your children:
Age Current health If deceased - age at death Cause of death, health issues

Exercise
Do you exercise?
- Yes
- No
List the forms of exercise you practice
Type of Exercise Frequency (per week) Duration (for how minutes per week)

Rest & Relaxation
Do you sleep enough for your level of activity?
- Yes
- No
How many hours do you sleep at night (on average)?
Do you practice regular relaxation? (e.g. meditation/reading/listening to music etc)
- Yes
- No

Medications
List any medications you are currently prescribed
Prescribed Medication What it's for Dose/Frequency Special Instructions
List any other preparations you are currently taking (i.e. Vitamins, Herbs, over the counter medications etc.
Other Preparation What it's for Dose/Frequency Special Instructions

Other Relevant Information
Do you think you are in good physical condition?
- Yes
- No
List any current health issues which, if resolved, would give you more peace and freedom.
How long do you want to live?
How long do you think you will live if you continue doing what you're doing now?
What specific aims do you intend to accomplish as a result of your participation in this service? How would you like to look and feel in 12 months from now?
What barriers or struggles do you anticipate might stop you from reaching your aims for health?

Patient Acknowledgement
Please enter your full name here and press the submit button below to acknowledge that the information you have provided in this questionnaire is true and accurate to the best of your knowledge.

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Other Relevant Information

Men

Women

Immunisations

Family History

Father's Details

Mother's Details

Current Health Practices

Exercise

Rest & Relaxation

Nutrition and diet

Medications

Other Relevant Information

Patient Acknowledgement

Age	Current health	If deceased - age at death	Cause of death, health issues

Age	Current health	If deceased - age at death	Cause of death, health issues

Type of Exercise	Frequency (per week)	Duration (for how minutes per week)

Prescribed Medication	What it's for	Dose/Frequency	Special Instructions