Wellness Health Check App 1Personal Details2Smoking3Nutrition4Alcohol5Physical Activity6Stress and Mood7Obesity8Tiredness and Fatigue9General Health10Mood HiddenKey First Name* Last Name* HiddenScore Employer HiddenEmployer*Please selectACFSBOCElgasMeditechGender* Male Female HiddenGenderPlaese selectFemaleMaleDate of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation Mobile Number Email Address* Home Postcode Health Reports* I allow Workactive to email me my health report 1. Do you smoke* Yes No I used to smoke1a. How often do you smoke cigarettes?*1-2 per week3-5 per week1 per day2-3 per day3-5 per day5-10 per day11-20 per daymore than 20 per dayHidden1a. How often do you smoke cigarettes? 1-2 per week 3-5 per week 1 per day 2-3 per day 3-5 per day 5-10 per day 11-20 per day more than 20 per day 2. How many serves of vegetables do you have per day ? (1 serve equals 1/3 of a cup) Less than 1 per day 1-2 per day 2-3 per day 3-4 per day 4-5 per day More than 5 per day3. How many serves of fruit do you have per day? nil 1-2 per day 3-4 per day 5-6 per day More than 6 per day4. How often do you eat breakfast? I don't eat breakfast 1-2 times per week 3-5 times per week daily5. What is the total number of spoons of sugar you add to your drink or food per day (e.g. with tea / coffee ) Zero 1-3 per day 3-5 per day 5-7 per day 7-9 per day6. How many serves of chips , biscuits , sweets do you have per day? Nil 1-2 per day 3-4 per day 5 or more per day7. How often do you eat white rice / white bread for dinner? I don’t eat white rice or white bread for dinner 1-2 times per week 3-5 times per week DailyDon't include brown or Basmati rice or bread that is 100% whole grain. 8. How many servings of fish do you eat per week?* Nil Once per week Twice per week Three or more times per weekEach serving is the size of your palm, or about ¾ cup of flaked fish. Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in omega-3 fatty acids.9. How often do you eat takeaway food or meals out (eg. Restaurant/café meals, hamburgers, fried foods, pastries)* Less than once per week 1-2 / week 3-5 / week 5-7 week10. How often do you drink soft drinks, energy drinks, flavoured milk containing sugar?* Nil Less than once per week 1-2 per week 3-5 per week 1 per day 2-3 per day 3-5 per day10a. How many times a week do you eat olive oil, vinegar and lemon juice with salad or other foods?* Less than once per week 1 per week 2-3 per week 3-5 per week10b. How many times a week do you eat natural unsweetened yogurt or fermented foods such as sauerkraut?* Less than once per week 1-2 per week 2-3 per week 3-5 per weekFor example, yogurt,kefir,kim-chi,sauerkraut,kombucha,etc. These foods should contain live and active cultures and should not be cooked.10c. How many times a week does your food include herbs such as oregano, basil, parsley, mint, rosemary?* Less than once per week 1-2 per week 2-3 per week 3-5 per week10d. How many times a week do you eat nuts and legumes ( beans, peas, chickpeas) or avocados?* Less than once per week 1-2 per week 2-3 per week 3-5 per weekA serving of nuts is a small handful of whole nuts, 1/4 cup chopped nuts or 2 tablespoons of nut butter. Avocado is 1/4 of a fruit or 1/4 cup of guacamole. 11a. Do you drink alcohol?* Yes No I used to drink11b. How often do you have a drink containing alcohol?* Social drinker less than 1 drink per week 1-2 drinks per week 3-5 drinks per week Daily More than 4 per day Less than 4 per day 14a. How much moderate physical activity do you do per day?Moderate: increases your heart rate and makes you breathe harder than normal (e.g. walking, gardening, dancing, golf, social tennis: 1K=1000 steps) 2k steps or less than 20 min 2k-4k steps or 20-40 min 4k-6k or 40-60 min 8k-10k or 80-100 min More than 150 min per day14b. Walking: which best describes how fast you normally walk? No one can keep up with me I walk above average speed I walk at average speed I walk at a slow pace I have trouble walking more than 50 metres or less at a time15a. How much time each week do you do vigorous physical activity?*Vigorous: makes you sweat or puff and pant (e.g. jogging, competitive sport, swimming, bike riding, aerobics or fitness class) Less than 30 min per week 30-60 min per week 60-80 min per week 80-120 min per week 120-150 min per week More than 150 min per week15b. How far can you safely squat* I cannot do a squat safely I can squat at least quarter way safely I can squat at least half way safely I can safely do a full squat15d. How much bodily pain have you had in past 4 weeks* Nil Little Some A lot All the time16. I can stand on my right leg without wobbling for 5 seconds or less 5-10 seconds Easily more than 10 seconds17. I can stand on my left leg without wobbling for 5 seconds or less 5-10 seconds Easily more than 10 seconds18. During the past 4 weeks, how much did your health interfere with your normal work or recreational activities?* Never Occasionally (1-2 times) Frequently (4-5 times) Constantly 19. During the past month have you often been bothered by feeling down, depressed, or hopeless?* Yes almost all the time Occasionally NeverHours Sedentary20. On average, how much time do you spend sitting or reclining each day? (includes work, home and travel)*This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television. Include time spent at work or at home. Less than 2 hours 3-5 hours 6-8 hours 9-11 hours more than 12 hours21. On average, do you sit for more than an hour without moving?* Yes No 22. What is your abdominal circumference in cm*Please enter a number from 60 to 180.23. In the past 12 months, has your weight changed? Remained the same Increased Decreased24. What is your BMI Under 20 21-24 25-30 31-40 41-45 Over 4625. Ab circumference Less than 80cm 81cm-85cm 86cm-94cm 95cm-104cm 105cm-112cm 113cm-120cm More than 120 cm 26. During the past week, what was the average number of hours sleep you had each night?* 5 hours or less 6-8 hours 9-11 hours 12-15 hours More than 16 hours27. Rate your sleepiness on an average day* Not sleepy at all Occasionally sleepy Sleepy a few times Frequently sleepy for no reason 28. Do you get at least 20 minutes per day of safe sun exposure Yes No29. In General, How would you say your health is?* Poor Could be better Average Good Very good Excellent30. Are you presently or have you in the past suffered from any of the following? Heart complaint Heart Disease High Blood Pressure Diabetes Pre Diabetes Metabolic Syndrome Stroke Other chronic illness such as Altzheimers or Dementia No problems with any of the above31. Do you know what your blood pressure is?* Yes No32. Do you know what your blood pressure is? Normal Pre-High stage 1 High stage 2 Don't know 33. On a scale of 1 to 10, with 10 being the happiest, how happy are you overall right now?10 being happiest and 1 not happy 10 9 8 7 6 5 4 3 2 134. On a scale of 1 to 10, with 10 being the happiest, how happy were you six months ago?10 being happiest and 1 not happy 10 9 8 7 6 5 4 3 2 1HiddenConsultation NotesHiddenConsultation Date DD slash MM slash YYYY