Online Lifestyle Medicine Assessment

1. Client information

Please complete one questionnaire per person.

Full name *

Date of birth *

Sex recorded at birth

Gender identity (optional)

Email address *

WhatsApp/mobile number *

Occupation or main daily role

Home addressUse the address format for your country. A postcode, Eircode or ZIP code is optional and may be included within the address.

2. Main concerns and symptom impact

Select all that apply. Additional questions will appear for selected concerns.

Current health concerns *

Describe your main symptoms and concerns *

How long have symptoms been present?

Overall symptom severity (0–10)

What makes symptoms worse?

What makes symptoms better?

How do these concerns affect your quality of life?

Urgent care: This form is not monitored for emergencies. Seek urgent medical help for chest pain, severe breathlessness, fainting, sudden weakness, severe or rapidly worsening abdominal pain, vomiting blood, black/bloody stools, or severe symptoms with very high blood pressure.

3. Medical, surgical and family history

Provide enough detail for a safe and meaningful lifestyle review.

Current and previous diagnosed conditions

Previous operations, procedures or hospital admissions

Current medicines and supplements

How often do you miss prescribed doses?

Medication side effects or concerns

Allergies and intolerances

Do you have allergies?

Food intolerances or foods avoided

Family history

Has a close biological family member had any of the following?

Family history details

4. Nutrition and eating pattern

Think about your usual pattern over the last four weeks.

Fruit

Vegetables or salad

Wholegrains

Beans, lentils or pulses

How often do you eat highly processed foods?Examples: packaged snacks, processed meats, instant meals and confectionery.

How often do you drink sugary drinks?Include fizzy drinks, energy drinks and sweetened juices.

Takeaways or fast food

Water intake per day (litres)

Salt use

Meals usually eaten daily

Eating within 2 hours of bedtime

Difficulty affording enough healthy food

Typical food and drink pattern

What would you most like to improve about your eating?

5. Movement, physical function and sedentary time

Days with at least 30 minutes activity/week

Strength activity days/week

Sitting hours on a usual day

Walking ability

Walking aid used?

Confidence exercising safely (0–10)

Usual activities and physical limitations

6. Sleep, stress and emotional wellbeing

Average sleep hours/night

Sleep quality

Loud snoring or witnessed pauses?

Current stress level (0–10)

Mood over the last two weeks

Relaxation or recovery days/week

Main sources of stress and current coping strategies

This questionnaire is not a crisis service. If you feel at immediate risk of harming yourself or someone else, contact emergency services or an urgent crisis support service now.

7. Tobacco, alcohol and other exposures

Smoking status

Vaping status

Alcohol frequency

Estimated alcohol units/week

Recreational drug use

Caffeinated drinks/day

Additional details or support wanted

8. Social connection and daily environment

Who do you live with?

How supported do you feel?

How often do you feel lonely?

Caring responsibilities

Housing, work, finances, transport or safety issues affecting health

9. Measurements and recent tests

Complete only what you know. Do not delay the form to obtain measurements.

Height (cm)

Weight (kg)

Waist circumference (cm)

Total cholesterol (if known)

HbA1c or glucose (if known)

Approximate test date

Other relevant results or reports

10. Goals, readiness and preferences

Your three most important health goals *

Readiness to make changes (0–10)

Confidence you can make changes (0–10)

Main barrier

One small change you feel ready to start

Cultural, accessibility, language or communication preferences

11. Declaration and electronic consent

All items are required before submission.

I confirm that the information provided is accurate to the best of my knowledge. I understand this assessment supports personalised lifestyle planning and does not replace diagnosis, emergency care or treatment from my GP or specialist. I will not stop or change prescribed medication without advice from my treating healthcare professional. I consent to Straddle Health & Wellbeing Services processing my personal and health information for this assessment and related care planning in accordance with applicable data protection law. By ticking this box and submitting, I confirm that my typed name constitutes my electronic signature and consent to proceed.

Typed full name *

Consent date *

Telephone services are unmanned. Please contact us by email or WhatsApp. Do not send emergency information through this form.

Device privacy: “Save draft” stores health information only in this browser on this device. Avoid using it on a shared or public device.

Straddle Lifestyle Medicine Assessment