Onboarding Form

1Some questions about you?

Are you filling this survey in for yourself?

Yes No

What is your date of birth?

What sex were you assigned at birth?

Male Female

Height (cm)

Weight (kg)

What is your waist circumference taken midway between the bottom of your ribs and your hip bone, or inline with your belly button? (cm)

2What are your main health goals?

Energy & Metabolic Health Better Balance, Manage Stress & Enhance Sleep Manage Symptoms of Menopause Improve Digestion & Gut Health Focus on Weight Loss Better Bones & Joints Improve Immunity Improve Hair, Skin & Nails

Energy & Metabolic Health

How would you rate your energy levels?

Do you have slumps during the day?

Yes No

Better Balance, Manage Stress & Enhance Sleep

How stressed have you been in the last month?

How often do you feel stressed?

Do you feel you have trouble focusing or concentrating on tasks?

Yes No

How often do you experience brain fog?

Do you need support with your short term memory?

Yes No

Manage Symptoms of Menopause

Have you started or completed menopause?

Yes No

Are you experiencing hot flushes?

Yes No

Are you experiencing weight gain?

Yes No

Are you experiencing mood swings?

Yes No

Are you experiencing headaches?

Yes No

Are you experiencing joint pain?

Yes No

Do you have vaginal dryness?

Yes No

Improve Digestion & Gut Health

Do any of these digestive health concerns relate to you?

Focus on Weight Loss

Would you like to achieve an optimal weight from the Precision Health Plan?

Yes No

I would like to lose:

Better Bones & Joints

Do you have a family history of bone issues (such as osteoporosis or osteoarthritis)?

Yes No

Are you concerned about or do you experience any of the below:

Have you previously been diagnosed with gallstones?

Yes No

Improve Immunity

In relation to colds, flu and infections - how often do you feel unwell each year?

Do you often get cold sores?

Yes No

Improve Hair, Skin & Nails

Describe your skin?

Describe your hair?

3Some questions about your lifestyle?

What types of physical activity would you do?

How many number of days of activity would you do per week?

How minutes per session of activity would you do per workout?

When it comes to exercise, your reason to get active is?

Could you describe the intensity of your exercise session?

Do you often experience muscle cramps or soreness after exercising?

Yes No

How many hours of sleep do you get in 24 hours? (approximately)

On a scale of 1 to 7, 7 being the highest, how exhausted do you feel in the morning (consider the average for a week)?

How long does it takes you to fall asleep once you are in bed?

In your opinion, how would you rate your quality of sleep?

How often do you get 20 min of sunshine (at least on your face and hands, without sunscreen)?

Do you experience visual fatigue at the end of the day from looking at screens? (Eyes may feel sore, dry or tired)

Do you drink alcohol (e.g champagne, wine, beer, spirits)?

Yes No

How many glasses (100ml) of white wine or champagne do you consume per week?

How many glasses (100ml) of red wine do you consume per week?

How many glasses (30ml) of spirts (e.g scotch, gin etc) do you consume per week?

How many glasses (150ml) of beer (e.g light, mid or full strength) do you consume per week?

Do you consume caffeinated beverages, coffee/ tea? If so, how many per day?

Have you been a smoker?

Yes No

How many cigarettes or cigars have you smoked in your lifetime?

4Some question about your diet

How would you describe your diet?

What type of dietary cuisine do you prefer?

How often would you eat this style of cuisine?

Do you regularly miss or skip a meal? if yes, could you indicate which meal?

Don't miss meals Breakfast Lunch Dinner

Do you have any dietary restrictions or preferences?

How often would you eat out per week?

Do you eat red meat (e.g beef, lamb, pork, veal, goat etc)?

Yes No

How many serves (~65g cooked) of beef would you eat per week?

How many serves (~65g cooked) of lamb would you eat per week?

How many serves (~65g cooked) of veal would you eat per week?

How many serves (~65g cooked) of pork would you eat per week?

How many serves (~65g cooked) of lean sausages would you eat per week?

How many serves (~65g cooked) of other lean red meat (e.g kangaroo) would you eat per week?

Do you eat processed meats (e.g cured meats like salami/ ham or sausages and bacon)?

Yes No

How many serves (~20 g) of cured meats (e.g salami, ham or prosciutto) would you eat per week?

How many serves (~65 g) of bacon would you eat per week?

How many serves (~65 g) of fatty sausages would you eat per week?

How many serves (~65 g) of minced meats (e.g beef or pork) would you eat per week?

Do you eat white meat (e.g. poultry like chicken or turkey)?

Yes No

How many serves (~80 g) of lean chicken would you eat per week?

How many serves (~80 g) of turkey would you eat per week?

How many serves (~80 g) of duck or goose would you eat per week?

How many serves (~80 g) of game birds (emu, bush birds, pidgeon) would you eat per week?

Do you eat seafood/ fish (e.g whiting, salmon, shell fish, canned fish, crab)?

Yes No

How many serves (~100g) of bass, whiting or swordfish fillets do you eat each per week?

How many serves (~100g) of barramundi or snapper fillets do you eat each per week?

How many serves (~100g) of salmon or trout fillets do you eat each per week?

How many serves (~100g) of canned fish (e.g sardines, tuna etc) do you eat each per week?

How many serves (~50g) of shell fish (e.g mussels, scallops etc) do you eat each per week?

How many serves (~100g) of crustaceans (e.g crab, lobster etc) do you eat each per week?

Do you eat green leafy vegetables (e.g. spinach, cabbage)?

Yes No

How many serves (~75g) of spinach, cabbage, wok chop, lettuce do you typically eat per week?

How many serves (~75g) of broccoli do you typically eat per week?

How many serves (~75g) of artichoke do you typically eat per week?

How many serves (~75g) of asparagus do you typically eat per week?

How many serves (~75g) of zucchini or cauliflower do you typically eat per week?

If you do not see a green leafy vegetable you eat, please include below (e.g. kale, 1x per week)

Do you eat starchy vegetables (e.g. potato, corn)?

Yes No

How many serves (~75g) of potato (e.g roast, chips/ fries, mashed) do you typically eat per week?

How many serves (~75g) of sweet potato (e.g roast, chips/ fries, mashed) do you typically eat per week?

How many serves (~75g) of parsnip do you typically eat per week?

How many serves (~75g) of corn do you typically eat per week?

How many serves (~75g) of taro/cassava do you typically eat per week?

How many serves (~75g) of turnip do you typically eat per week?

If you do not see a starchy vegetable you eat, please include below (lima beans, 1x per week)

Do you eat beans, legumes or tofu?

Yes No

How many serves (~75g) of lentils do you typically eat per week?

How many serves (~75g) of chickpea do you typically eat per week?

How many serves (~75g) of broad beans do you typically eat per week?

How many serves (~75g) of black beans do you typically eat per week?

How many serves (~75g) of pinto/berlotti beans do you typically eat per week?

How many serves (~75g) of tofu do you typically eat per week?

How many serves (~75g) of green beans or peas do you typically eat per week?

If you do not see a legume vegetable you eat, please include below (peanuts, 1x per week)

Do you eat orange vegetables (e.g. carrot, capsicum)?

Yes No

How many serves (~75g) of carrot do you typically eat per week?

How many serves (~75g) of capsicum do you typically eat per week?

How many serves (~75g) of pumpkin do you typically eat per week?

How many serves (~75g) of beetroot do you typically eat per week?

If you do not see an orange vegetable you eat, please include below

Do you eat other vegetables (e.g onion, mushroom, tomato, avocado)?

Yes No

How many serves (~75g) of onion do you typically eat per week?

How many serves (~75g) of cucumber do you typically eat per week?

How many serves (~75g) of tomato do you typically eat per week?

How many serves (~75g) of mushroom do you typically eat per week?

How many serves (~75g) of avocado do you typically eat per week?

How many serves (~75g) of eggplant do you typically eat per week?

If you do not see a vegetable you eat, please include below

Do you eat fruit (apples, bananas etc) or dried fruits (sultanas, dates etc)?

Yes No

How many serves (~150g) of apples do you typically eat per week?

How many serves (~150g) of banana do you typically eat per week?

How many serves (~150g) of orange/mandarin do you typically eat per week?

How many serves (~150g) of pear do you typically eat per week?

How many serves (~150g) of strawberry do you typically eat per week?

How many serves (~150g) of blueberry/blackberry do you typically eat per week?

How many serves (~150g) of rasberry do you typically eat per week?

How many serves (~150g) of watermelon/rockmelon do you typically eat per week?

How many serves (~30g) of dried fruits (e.g sultanas/ dates/ apricots) do you typically eat per week?

If you do not see a fruit or dried fruit you eat, please include below (kiwi fruit, 1x per week)

Do you drink milk (cows, almond, soy) including in your tea or coffee?

Yes No

How many serves (250ml or 1 glass) of full cream milk do you drink per day?

How many serves (250ml or 1 glass) of low fat milk do you drink per day?

How many serves (250ml or 1 glass) of skim milk do you drink per day?

How many serves (250ml or 1 glass) of soy milk do you drink per day?

How many serves (250ml or 1 glass) of almond or oat milk do you drink per day?

Do you eat yogurt (low fat, greek etc)?

Yes No

How many serves (200g) of full fat yogurt do you eat per week?

How many serves (200g) of low-fat, plain yogurt do you eat per week?

How many serves (200g) of low-fat, fruit flavoured yogurt do you eat per week?

How many serves (200g) of no-fat yogurt do you eat per week?

Do you eat cheese (cheddar/ cheese slices, soft cheeses etc)?

Yes No

How many serves (~40g) of hard cheese/ cheddar/ parmesan do you typically eat per week?

How many serves (~120g) of soft cheeses (e.g. ricotta, feta) do you typically eat per week?

Do you eat cereals or bread (e.g. cooked rice, pasta, noodles, barley, buckwheat, semolina, polenta, bulgur or quinoa, wheat cereal flakes or muesli)?

Yes No

How many serves (2 slices) of wholegrain or high fibre bread do you typically eat per day?

How many serves (2 slices) of white bread, roll or flat bread do you typically eat per day?

How many serves (~75g) of rice, pasta, noodles, barley, buckwheat, semolina, polenta, bulgur or quinoa do you typically eat per week?

How many serves (~75g) of porridge/ oats do you typically eat per week?

How many serves (~75g) of muesli do you typically eat per week?

How many serves (~75g) of wheat/corn cereal do you typically eat per week?

How many serves (~75g) of crisp breads do you typically eat per week?

How many serves (~75g) of crumpets do you typically eat per week?

How many serves (~75g) of English muffin do you typically eat per week?

If you do not see the cereals or breads (carbohydrates) that you eat, please include below (e.g. carb name, 1x per week)

Do you eat nut or nut paste (e.g peanut butter)?

Yes No

How many serves (30g) of peanuts or nut paste (e.g. peanut butter) do you eat during the week?

How many serves (30g) of walnuts do you eat during the week?

How many serves (30g) of almonds or nut paste (e.g. almond butter) do you eat during the week?

If you do not see the nut or nut paste that you eat, please include in below (e.g. nut name, 1x per week)

How many serves (2 whole) of eggs would you eat per week?

Do you cook with plant oils (olive, sesame, coconut) or butter etc?

Yes No

How many times do you cook (or add to bread) with butter per week?

How many times do you cook (or add to bread) with margarine per week?

How many times per week do you cook with olive oil per week?

How many times per week do you cook with sesame oil per week?

How many times per week do you cook with sunflower oil per week?

How many times per week do you cook with coconut oil per week?

How much water do you drink per day?

Do you consume sweet snacks?

Yes No

How many glasses (250 ml) of sugar sweetened soda drinks (e.g. coke, lemonade) do you drink per week?

How many glasses (250 ml) of fruit juices (e.g. orange) do you drink per week?

How many serves (2 scoops) of ice cream do you eat per week?

How many serves (35g) of chocolate do you eat per week?

How many serves (5g) of jam do you eat per week?

How many serves (5g) of honey do you eat per week?

How many serves (~25g) of biscuits do you eat per week?

How many serves of donuts do you eat per week?

If you do not see the sweet snacks that you eat, please include below (e.g. item name, 1x per week)

Do you consume salty snacks (e.g potato chips/ pop corn/ pies)?

Yes No

How many serves (~35g) of potato chips do you eat per week?

How many serves (~35g) of popcorn do you eat per week?

If you do not see the salty snacks that you eat, please include below (e.g. item name, 1x per week)

Please confirm that the answers to your weekly food diary add to 7 breakfasts, 7 lunches, 7 dinners, as well as snacks and what you use to cook the meals (when relevant)?

5Some questions about your general health

Are you currently taking Vitamins and Dietary Supplements?

Yes No

List all Vitamin or Dietary Supplements you are taking. Provide the item’s name, dosage, quantity taken and times per day separated by commas. e.g. vitamin or supplement name, 250mg, 2, 1

Who recommended the Vitamins and Dietary Supplements you are taking?

How long have you been taking these?

What is the reason you are taking the supplements?

Has your medical practitioner/ GP/ specialist clinician recommended that you take any supplements?

Yes No

List all supplements you are taking for medical reasons. Provide the item’s name, dosage, quantity taken, times per day and how long you’ve been taken it for separated by commas e.g. supplement name (iron, magnesium, other), 250mg, 2, 1, 6 months

Are you currently taking any medication(s)?

Yes No

List all medications you are taking. Provide the item’s name, dosage, quantity taken, times per day and how long you’ve been taken it for separated by commas e.g. medicine name, 250mg, 2, 1, 6 months

Please list all conditions separating each condition with a comma e.g. Blood pressure, hormone replacement, reflux

If you have previously taken other medications for any of these conditions, please provide the name of the medicine, the prescribed dosage and the frequency you took the dosage for each condition as best as you can recall.

Have you taken any antibiotics in the last 6 months?

Yes No

Do you have a family history of any medical conditions? Please provide the condition and then the relative (noting on maternal or paternal side) separated by a commas, e.g. Breast cancer, Maternal Grandmother; Diabetes, Paternal cousin, etc. Please try to be as extensive as possible.

How often are you having a bowel movement?

How would you describe your bowel movement?

Are you allergic to any of the following?

Do you feel you need support with your urinary tract health?

Yes No

Welcome to vivaBALANCE

Let’s talk Lifestyle

Let’s talk Health

1Some questions about you?

2What are your main health goals?

Energy & Metabolic Health

Better Balance, Manage Stress & Enhance Sleep

Manage Symptoms of Menopause

Improve Digestion & Gut Health

Focus on Weight Loss

Better Bones & Joints

Improve Immunity

Improve Hair, Skin & Nails

3Some questions about your lifestyle?

4Some question about your diet

5Some questions about your general health