Full name *
Phone number *
Email address *
Date of birth *
1. Do you have any chronic illnesses or medical conditions? * Yes No
If yes, please list them.
2. Have you had any surgeries or hospital stays in the past 5 years? Yes No
If yes, please detail.
3. Are you currently taking any medications or supplements? * Yes No
If yes, please list all, including over-the-counter drugs and supplements.
4. Do you have any known allergies (medications, food, or other)? Yes No
If yes, please list.
5. Are there any chronic illnesses or conditions in your family that we should be aware of? Yes No
If yes, please detail relations and diagnoses.
Lifestyle and Routine
6. Please describe your typical daily diet in as much detail as you can: breakfast/snack/lunch/snack/dinner/snack. *
7. Please describe your typical weekly physical activity of all kinds in as much detail as you can.
8. Please describe your typical daily routine in as much detail as possible.
9. On average, how many hours of sleep do you usually get per night? <6 hours 6-7 hours 7-9 hours >9 hours
Mental Fitness
10. Over the past 2 weeks, how often have you felt down, depressed, or hopeless? Never Occasionally Sometimes Often Always
11. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things? Never Occasionally Sometimes Often Always
12. Are you currently experiencing anxiety, stress, or significant worry? Yes No
If yes, please list any specific concerns.
Substance Use
13. Do you smoke tobacco or use any nicotine products? Yes No
14. How much alcohol, do you typically consume per week? 0 units 1 - 7 units 7 - 14 units 14 - 21 units >21 units
15. Do you use recreational drugs? No Yes
If yes, please specify which substances and the frequency of use.
Additional Questions
16. What are your main goals you would like to achieve in this programme? *
17. Have you participated in any other health or wellness programmes in the past?
If yes, please describe your experiences and outcomes.
18. How would you rate your current level of satisfaction with your health and wellness on a scale of 1 to 5? 1 2 3 4 5
Consent and Preferences
19. Do you consent to storing your information securely and electronic communication for the purposes of health monitoring and consultation in line with GDPR and CQC regulations? (You may withdraw consent at any time) * Yes No
20. Do you have any accessibility needs or preferences for communication that we should be aware of to better assist you during the program? Yes No
If yes, please specify.
21. Is there anything else you feel is important for us to know in order to best support your health goals?
