• Welcome to Rehab Management's Lifestyle Assessment. Your health is important to us, so we request that all information is filled out to the best of your ability. This will assist us to guide any future coaching program.

    We hold all your responses in the strictest of confidence. At Rehab Management we aim to build trust through meaningful interactions and we look forward to reviewing your results upon completion of the assessment.

    Please read the following statements, which relate to your current life at home and work, and indicate
    how each statement impacts you. This questionnaire is designed to increase your awareness of your lifestyle and risk factors on your physical well-being.

    All fields marked with an * are mandatory.

    Completion of the assessment will only occur once you click the submit button. If you decide not to finish and/or not to submit the screening your responses will be lost and deleted from the system.

     
  • Gender*
  • Department*
  • Location*

  • Please input a valid mobile number and click Confirm. A SMS validation code will be sent to your mobile. Enter the validation code and click Confirm.

     

  •   Please ensure the phone number does not start with a '0' (zero) e.g. +61444444444  

  • Date of Birth
     / /
  • Waist circumference (in centimetres)*
  • How many days off work due to illness in the past 6 months?*
  • Is there a history of heart disease in your parents, grandparents, siblings?*
  • Is there a history of cancer in your parents, grandparents, siblings?*
  • Have you been diagnosed with diabetes?*
  • What is your blood sugar (glucose)?*
  • What is your blood cholesterol?*
  • What is your systolic blood pressure (the first / top value)?*
  • What is your diastolic blood pressure (the second / bottom value)?*
  • Do you take medication for high blood pressure?*
  • Are you or have you been a smoker?*
  • Do you regularly eat three main meals a day?*
  • How many fruit & vegetable portions do you have per day?*
  • How many red or processed meat meals per week?*
  • How many fish or legume (beans, lentils) meals per week?*
  • How many fat-fried meals per week?*
  • How would you describe consumption of sweets, cakes, chips, similar?*
  • How many alcoholic drinks per week - 1 drink = pot or glass wine 100ml?*
  • How is your alcohol consumption spread through the week?*
  • How many minutes of moderate activity or exercise do you do per week (involve effort, but you can still talk)?*
  • How many minutes of strenuous physical activity per week (make you breathe harder and faster)?*
  • Do you have trouble falling asleep at night?*
  • Do you wake in the night and have difficulty going back to sleep?*
  • How many hours on average do you sleep each night?*
  • How close to bedtime is your last tea/coffee/cola/ other caffeine drink?*
  • How many standard caffeinated drinks do you have a day?*
  • How do you feel you are coping with the pressures of work?*
  • How do you feel you are coping with the pressures of home life?*
  • How do you consider your current state of mental and physical health?*
  • Do you experience sudden feelings of anxiety?*
  • Do you currently feel under financial pressure?*
  • How much support do you receive from colleagues or people around you in the day?*
  • How much support do you receive from friends and family?*
  • Do work issues and needs intrude on your home life?*
  • Awareness. Do you believe your awareness of your health and wellbeing has improved as a result of this program?*
  • Action. Have you taken action to improve your heath and wellbeing as a result of this program?*
  • Future. Do you feel more confident to self manage your health and wellbeing in the future as a result of your participation in this program?*
  • Should be Empty: