Medical

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Program Code

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Child

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Survey Form

Please select yes or no for each of the medical questions below.

The information you provide will ensure your Health coach is aware of any relevant medical issues. Unless you advise us otherwise, we will also send a letter to your GP informing them of your participation on the program.

Have you been diagnosed with Type 1 or Type 2 diabetes*

Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)?*

Have you ever been found to have high blood glucose (sugar) (for example, in a health examination, during an illness)?*

Are you currently following a special diet prescribed by a dietitian?*

Do you have any allergies, including food allergies?*

Have you ever needed to see a psychiatrist, psychologist or counsellor?*

Have you been diagnosed with any type of behavioural or psychological conditions (e.g. ADHD, Autism, anxiety, learning difficulties)?*

Do you have any visual/hearing disabilities?*

Do you have any other disabilities?*

Are you currently on any medication?*

Has the doctor ever said that you need to check with them before you participate in any type of physical activity?*

Do you ever feel pain in your chest when exercising?*

In the past month, have you felt pain in your chest when NOT doing physical activity?*

Do you ever lose consciousness or your balance because of dizziness?*

Do you have any bone or joint problem that could be made worse by a change in physical activity?*

Does you take any medication for blood pressure, a heart condition or any other condition?*

Can you think of any reason why you should not do physical activity?*

Are you awaiting any tests to be undertaken or on results from any tests completed to rule out any possible medical condition(s)?*

If you answered yes to any of the above, please give details:*

Any other relevant information:

If after completing this questionnaire you have any doubts or concerns about participating in the Think, Eat and Move program please inform your Health coach and / or contact your GP.