Health Questionnaire - Active X Health

PERSONAL INFORMATION

HEALTH INFORMATION

The more you tell me, the more I can help!

Please list your main health concerns – either because you have it/them, or simply wish to avoid it/them (e.g. back pain, diabetes, heart disease, mental health, overweight):

Do you have any other health concerns and/or goals?

How many hours do you work each week on average?

What role do sport and exercise play in your life? Please give details of frequency and duration of each activity:

Amount of screen-time -TV, computer, phone - outside of your work (e.g. 3 hours per day):

How active is your work?

Mostly sedentary

50/50 mix of sitting and movement

Mostly active

Not working

Any healers, doctors, helpers, or therapists you are currently consulting? Please list:

Do you take any medications (prescribed or not)? Please list, including dosages and frequencies:

Any allergies or sensitivities? Please explain:

Any constipation/diarrhea/gas? *

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother? List any persistent/life-threatening illnesses

How is/was the health of your father?

How is your sleep?

How many hours of sleep do you get on average each night?

Do you wake up through the night?

How do you feel when you get up after sleeping?

Do you have any pain, stiffness, or swelling anywhere?

At what point in your life did you feel your best?

FOOD INFORMATION

Time to confess...

What foods did you like to eat as a child? *

What is your food like these days? Do you follow a recognisable regime or just eat most things?

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked/prepared from scratch?

Up to 25 %

50 - 50 %

Up to 75 %

100 %

Where do you get the rest from? (e.g. packaged/processed, take-aways, restaurants)

Please describe your typical breakfast:

Please describe your typical lunch:

Please describe your typical evening meal:

Do you crave sugar, coffee, alcohol, cigarettes, or have any major addictions?

Approximate weekly consumption of cigarettes/tobacco (no. of units):

Any snacks, and when do you have them?

Approximate weekly consumption of alcohol (no. of units):

Approximate daily consumption of caffeinated coffee/tea (no. of units):

Would you like your current weight to be different?

If yes, what loss/gain would you like to make?

List other non-medical drugs / supplements, including dosages and frequencies:

“I believe that the most important thing I think I should do to improve my health is...” (please, complete the sentence):

Anything else you would like to share?