ACH Premium Express Questionnaire - Aspen Corporate Health

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Personal Details

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Contact Number*

Email*

Employment Details

Company*

Position

Work Email

Work Phone

Emergency Contact Details

Name*

First Last

Phone*

Medical History

Family History

Please select all that apply

Alzheimer’s Disease

High Blood Pressure

Elevated cholesterol

Cardiovascular Disease

Stroke

Heart Attack

Depression / Anxiety

Diabetes Type I

Diabetes Type II

Inflammatory Bowel Disease

Multiple Sclerosis

Lupus

Rheumatoid Arthritis

Obesity

Haemachromatosis

Leukemia/Lymphoma

Breast Cancer

Colorectal/Bowel Cancer

Ovarian Cancer

Prostate Cancer

Lung Cancer

Other Cancer

Melanoma

Glaucoma

Kidney Disease

Osteoporosis

Asthma

Other

Please specify

Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?*

Yes

Where were you born?*

Please select one

Australia

North or South America

Asia (including the Indian sub-continent)

Africa

Europe

Other

Please specify

Personal History

Have you ever experienced or been diagnosed with any of the following?

High Blood Pressure

Elevated cholesterol

Extra heart beats or skipped beats

Abnormal ECG

Heart Attack

Coronary Heart Disease

Stroke

High blood glucose reading

Diabetes Type I

Diabetes Type II

Difficulty breathing

Frequent cramps in your legs

Varicose Veins

Blood clots or Deep vein thrombosis

Dizziness or fainting spells

Epilepsy

Anxiety

Depression

Breast Cancer

Colon Cancer

Prostate Cancer

Chronic Fatigue

Benign Prostate enlargement

Bronchitis / Chronic Bronchitis

Sleep Disorders

Being out of breath while sitting or sleeping

Rheumatoid Arthritis

Low Iron Stores (Anaemia)

High Iron Stores

Thyroid Problems

Migraines or Headaches

Chronic or recurring morning cough

Kidney Stones

Difficulty with urination i.e. pain, poor flow

Rectal bleeding

Gout

Stomach of Intestinal problems i.e. recurrent heart burn, ulcers, constipation or diarrhea

Inflammatory Bowel Disease

Irritable Bowel Syndrome

Difficulties with hearing

Difficulties with vision

Fibromyalgia

Hayfever

Menopause

Osteoarthritis

Back Pain

Osteoporosis

Other

Please specify

Examination History

When was your last physical examination?

Please outline any other medical or diagnostic tests you have received in the past two years:

Prescription Medication

Do you take any prescription medication for the following?

High Blood Pressure

Cholesterol

Diabetes

Name/type of medication

Please list any other prescription or self-prescribed medications or dietary supplements you are currently taking and the condition they are for:

Lifestyle

Physical Activity

How much physical activity do you do outside of work?

What physical activities do you participate in?

Alcohol consumption

What is your average alcohol consumption?(standard drinks/day)

Alcohol free days per week?

Zero

1 - 2

3 - 4

5 - 7

non-drinker

Which best describes your smoking status?

Caffeine consumption

How many serves a day? i.e. coffee, tea, energy drinks and soft drinks

Diet

Per day, how often do you consume the following:

Water

Glasses per day

Protein - Meat and legumes

(peas, beans, chickpeas, etc.)

Two serves of dairy products

Carbohydrates

(Bread, rice, potato, pasta, cereal and grains)

Fruit

Vegetables

How often do you have takeaway/fast foods?

Relationships and Mental Health

Are you currently married or in a long term relationship?

Yes

Do you consider your partner to be a close friend with whom you can share your feelings, problems and accomplishments?

Yes

Do you feel that you have friends or family who provide you with the emotional support you need?

Yes

Stress

Please rate your perceived stress level in the last month*

(1= low stress, 10= very high stress level)

What are the main contributing factors?

Work

Home

Money

Health

Relationship

Non of the above

Please rate your current work / life balance*

(1= well balanced, 10= unbalanced)

K10 Psychological Stress Questionnaire

In the last 4 weeks, how often did you feel tired for no reason?*

In the last 4 weeks, how often did you feel nervous?*

In the last 4 weeks, how often did you feel so nervous that nothing could calm you down?*

In the last 4 weeks, how often did you feel hopeless?*

In the last 4 weeks, how often did you feel restless or fidgety?*

In the last 4 weeks, how often did you feel so restless that you could not sit still?*

In the last 4 weeks, how often did you feel depressed?*

In the last 4 weeks, how often did you feel that everything was an effort?*

In the last 4 weeks, how often did you feel so sad that nothing could cheer you up?*

In the last 4 weeks, how often did you feel worthless?*

Sleep

Do you go to sleep and wake up at approximately the same time each day, 7 days a week?

Yes

How many hours of sleep do you get per night (average)?

Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea or narcolepsy?

Yes

Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep?

Yes

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you.

Sitting and reading*

Watching TV*

Sitting, inactive in a public place (i.e: movies or meeting)*

As a passenger, in a car for an hour without a break*

Lying down to rest in the afternoon when circumstances permit*

Sitting and talking to someone*

Sitting quietly after a lunch without alcohol*

In a car, while stopped for a few minutes in the traffic*

Informed Consent for Physical Testing*

I have read this form and I consent to participate in the assessments and / or exercise test.

After you have completed the health and lifestyle questionnaire your health professional will assess the risk factors and determine if you are able to perform all, or some of the tests included in the assessment. After reading the following, your consent is required, and the form is to be signed in the presence of the health professional.

Risks and Discomforts
There exists the possibility of certain changes occurring during exercise. They include abnormal blood pressure, fainting, disorder of heartbeat, and in very rare instances, heart attack or death. Every effort will be made to minimise these through the preliminary examination and by observations during testing. Emergency equipment and trained personnel are available to deal with any emergencies.

Benefits to be expected
The results obtained from the assessments and the exercise test may assist in the diagnosis of illness. The results may also assist in evaluating what type of physical activity is suitable for you to engage in with minimal or no risk.

Questions
Questions about the procedures used in the assessments and / or exercise test, or in the estimation of functional capacity are encouraged. Should you have any doubts or questions, please ask for further explanation.

Freedom of Consent
Your permission to perform these assessments and / or exercise test is voluntary. You are free to deny consent if you so desire.