Consent And Release For Screening
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3CONSENT AND RELEASE FOR SCREENING
This form
must be completed
before your screening
Page 1/3
Screening Type:
Screening Location:
First Name:
Surname:
Email:
(Print Block)
Tel:
D.O.B:
M / F
(Home / Mobile)
(Date of Birth)
(Gender)
Your Lifestyle
Please answer the following with regard to your current lifestyle:
Do you take regular exercise?
YES
NO
If ‘YES’, what kind and how often, please list:
Do you feel you get enough sleep?
How many hours average each night?
YES
NO
Describe the quality of a typical night’s sleep?
Do you feel awake & alert during the day - Overall?
YES
NO
Not at all (1) - (2) - (3) - (4) - (5) All of the time (Circle)
Do you get tired at particular times of the day?
YES
NO
How would you classify your current overall stress levels?
YES
NO
Not stressed at all (1) - (2) - (3) - (4) - (5) Very Stressed (Circle)
Would you consider yourself to be a healthy eater?
YES
NO
How many portions of fruit and vegetables do you eat a day?
(None) - (1) - (2) - (3) - (4) - (5) - (5+) (Please Circle)
Do you follow a specific diet?
(food intolerance, vegetarian, vegan, etc.)
YES
NO
If ‘YES’, please list:
Do you consume caffeinated drinks on a regular basis? (coffee, tea, energy drinks, caffeine supplements)
YES
NO
If ‘YES’, how many per day?
Do you drink Alcohol?
YES
NO
If ‘YES’, how many units per week?
Do you smoke?
YES
NO
If ‘YES’, how many and how often?
Have you recently given up smoking?
YES
NO
(Never Smoked) - (<6m) - (6m-5y) - (5y+)
Which key area would you like to target over the next 12 months?
Please detail below: (i.e. weight loss, fitness, improved diet, etc.)
Family Health History
Please answer the following considering your blood relatives (siblings, parents, grandparents):
Do you have a family history of diabetes? Type 1 / Type 2
YES
NO
Do you have a family history of high blood pressure (hypertension)?
YES
NO
Do you have a family history of high cholesterol?
YES
NO
Do you have a family history of heart disease?
YES
NO
Do you have a family history of anaemia or iron overload (hemochromatosis)?
YES
NO
Do you have a family history of osteoporosis?
YES
NO
Do you have a family history of thyroid problems (over-active / underactive)?
YES
NO
Do you have any other family illness history or concerns not listed above?
YES
NO
If ‘YES’, please explain:
| keeping you on your perch!
Screenetics UK Limited, Registered in England No. 06151366.
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