Wellbeing Report Form

This form will only take 10-15 minutes to complete. Please answer every question and review your answers before submitting.

Your details

Enter date of birth above

Stage 1 (Compulsory)

Q7. Current physical activity in a typical week

Enter sessions per week and total minutes for each intensity. Weighted minutes = light + moderate + 2 × vigorous.

Able to maintain a conversation. Often ~60 minutes.

Talking is possible. ~30–60 minutes.

Hard to talk. Often up to 30 minutes. Very hard ≤ 10 minutes.

Weighted total: —

Stage 2 (Recommended with an exercise professional)

Demographics and behaviour
Body composition
Enter height and weight
Family history of heart disease
Select “None” or add at least one relation & age.
Blood pressure
/
Cholesterol and blood lipids
Blood sugar
Other health items

Gut Health Intake

Section A: Health and medication
Section B: Bowel habits and gut symptoms
Bristol Stool Scale: 1 hard lumps, 2 lumpy sausage, 3 sausage with cracks, 4 smooth soft, 5 soft blobs, 6 fluffy pieces, 7 watery. Between 3 to 5 is often ideal.
Gut symptoms severity
0 none, 1 mild, 2 moderate and 3 severe
Section C: Dietary pattern
Section D: Food and drink frequency

Your usual portion sizes over the past 3 months. Select all the food groups that are applicable.

Section E: Supplements and functional foods
Probiotic
Usual frequency
Prebiotic fibre
Usual frequency
Collagen
Usual frequency
Omega 3
Usual frequency
Vitamin D
Usual frequency
Multivitamin
Usual frequency
Other
Usual frequency
Section F: Meal timing and context
Weekday
Weekend
Section G: Recent changes
Section H: Additional notes and goals