Comprehensive Biometric Data Form: Dr Kate Staveley

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1. A PDF copy of this form will be sent to the Dr Kate Staveley - Main Drive>>KS Comprehensive Output Folder

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Type of Medical *

Use Semble template for standard Lifestyle GP appointment

Advanced Lifestyle GP Assessment

Longevity Consultation

Other:

Name *

Client email *

Today's Date *

YYYY

Date of Birth *

YYYY

Address *

ID confirmed? *

Thank you for confirming your ID at the outset of our consultation together.

Unfortunately, you were unable to bring formal ID with you to this consultation.

Venue
*

Windsor

Weybridge

online

Other:

How would you describe your ethnicity?
*

Current Symptoms and Health Concerns *

Past Medical History

Family History

Current Medication

Allergies

What is most important to you and your health? *

Physical Activity - Summary *

adequate

inadequate

You undertake the following minutes of exercise per week *

Diet - number of different plant based foods per week *

Nutrition - processed foods and/or takeaways per week
*

less than 1

more than 5

Stress level - number from questionnaire *

Sleep - hours on a weekday
*

less than 7

7-9

more than 9

Sleep - hours on a weekend
*

less than 7

7-9

more than 9

Sleep - Quality
*

How many drinks containing caffeine would you have in a typical day? *

1-4

5-9

more than 10

How many of these caffeine-containing drinks are after 2pm?

Social - satisfaction with life *

Social - do you have supportive relationship/friendships *

"Yes"

"No"

"Maybe"

Alcohol - recommended limit *

within

above

Smoker *

"Yes"

"No"

Oxygen Saturation (%) *

Systolic Blood Pressure *

Diastolic Blood Pressure *

Blood Pressure - range *

Normal

Borderline raised

High

Heart Murmur

No Heart Murmurs

Murmur Found

Clear selection

ECG
*

Height (cm) *

Weight (kg) *

Body Mass Index (BMI)
*

BMI - range *

Underweight

Normal

Overweight

Obese

Visceral Fat
*

Visceral Fat - range *

Healthy

Borderline

Unhealthy

Waist Circumference (cm) *

Waist Circumference - range *

Normal

Borderline raised

High

Waist to Height Ratio *

Waist:Height Ratio - Range

Low Risk

Medium Risk

High Risk

Clear selection

3-minute step test *

3min step result *

Excellent

Good

Average

Below Average

Poor

Other:

Step Test Reference Ranges

Grip Strength Value (kg)

Using a dynamometer take three readings from each side with elbow by side flexed at 90 degrees. Patient should be standing. Add all these together and take average. Apply to tables below

Average Grip Strength

Strong

Normal

Weak

Clear selection

Grip Strength Reference Values

Full Blood Count *

Normal

Other:

High Sensitivity CRP *

Normal suggesting no signs of inflammation

Elevated suggesting above normal levels of inflammation

Kidney Function *

Normal

Abnormal, showing signs of impairment

Other:

Liver Function *

Normal

Abnormal, showing signs of impairment

Other:

Gamma GT *

Normal

Abnormal. This may indicate liver inflammation and should be discussed with your GP

Other:

HbA1c *

Normal

Abnormal, in the pre-diabetes range. I recommend you discuss this with your GP

Abnormal, in the diabetes range. I recommend you discuss this with your GP

Abnormal, in the pre-diabetes range. You and your GP already know this

Abnormal, in the diabetes range. You and your GP already know this

Other:

Cholesterol *

Normal

Showing a raised LDL level (bad cholesterol)

Showing a significantly raised LDL (bad cholesterol) level which I recommend you discuss with your own GP

Showing low HDL (good cholesterol) levels which can be addressed through lifestyle changes

Other:

B12 *

Normal

Marginally low. This can be addressed through your diet. Further information is available at https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/

Low. I recommend you discuss this with your own GP

Other:

Folate *

Normal

Marginally low. This can be addressed by increasing folate rich foods in your diet. Further information is available at https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/

Low. I recommend you discuss this with your own GP as a supplement may need to be prescribed. It would also be sensible to increase folate rich foods in your diet. Further information is available at https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/

Other:

Vitamin D *

Normal

Insufficient. This can be addressed by aiming to get 20 minutes of midday sunlight, several times a week. People with dark skin may need a little more than this. Also consider taking a daily supplement containing 10 micrograms of Vitamin D from October to March

Deficient. I recommend you discuss this your own GP as higher level supplements may need to be prescribed

Other:

Ferritin *

Normal

Suboptimal. This can be improved through eating more iron rich foods in your diet. Further information is available at https://www.nhs.uk/conditions/vitamins-and-minerals/iron/

Low. I recommend you discuss this with your own GP

Other:

Thyroid *

Normal

Mildly abnormal. I recommend this be repeated in 8 weeks. Please discuss this with your own GP

Abnormal. I recommend you discuss this with your own GP

Other:

Uric acid

Normal

Slightly raised

High. I recommend that you discuss this with your own GP

Other:

Clear selection

Homocysteine level

normal

raised

Clear selection

Your QRISK3 calculation is: (%)

Please delete paragraph in output letter if this is not applicable due to pre-existing heart disease/stroke

QRISK - interpretation compared to average

lower than

the same as

higher than

Clear selection

QRISK3 Healthy Heart Age (in years)

Dementia Risk (%)

Use calculator found at: https://www.projectbiglife.ca/calculators/dementia. NB Only available for those aged 55 and over. Risk < 1% is considered low risk and a risk above 5% is considered high risk.

FRAX Score (%)

https://frax.shef.ac.uk/FRAX/tool.aspx?country=1

Major Osteoporotic Fracture Risk Value

Risk

very high risk

high risk

intermediate risk

low risk

Clear selection

NOGG outcome recommendation

"consider specialist referral and treat". For this reason we recommend you see your GP with a copy of this report.

"treat". For this reason we recommend you see your GP with a copy of this report.

"measure bone mineral density (BMD)". For this reason we recommend you see your GP with a copy of this report.

"give lifestyle advice" which we will cover in the rest of this report.

"treat". You are already taking medication for this.

Clear selection

Lung Disease Risk

low (less 1% as a non-smoker)

moderate (over 1% as an ex-smoker)

high (over 10% as a current smoker)

Other:

Clear selection

Cancer Risk (%)

www.qcancer.org

Cancer Risk Compared

This found also on the Qcancer risk assessment

lower than

the same as

higher than

Clear selection

Diabetes Risk (%)

www.qdiabetes.org

Diabetes Risk - interpretation

Low risk = less than 3

Moderate risk = 3 to 10

High risk = QDiabetes >10% or HbA1c>47

low risk

moderate risk

high risk

Clear selection

Based on your medical assessment as detailed above, making changes to your lifestyle will have the following benefits: *

- cancer risk reduction, - weight reduction, - better cholesterol/BP/diabetes

Stage of Change *

Precontemplation stage of change in which people in this stage do not consider their behaviour to be a problem

Contemplation stage of change in which people start to think about changing their behaviour, but aren't committed to it yet. They may weigh the pros and cons of change

Preparation stage of change in which people are committed to change and are actively looking for information to help them

Action stage of change in which people have made observable changes to their lifestyle within the past six months

Maintenance stage of change in which people have developed the skills to maintain their new behaviour and feel confident in their ability to do so

Relapse

Physical Activity *

purposefully park far away and walk more

go for a walk at lunchtime for 30 minutes

when watching TV, move during the adverts

instead of using the lift or escalator, use the stairs

do 250 minutes a week of moderate exercise to avoid weight regain

do 300 minutes a week of moderate exercise for weight loss

Other:

Required

Nutrition *

replace meat with plant-based proteins twice a week

reduce simple and refined carbohydrate processed grains

prepare and eat 1 cup of beans in lunch or dinner every day for 3 months

use a balsamic vinaigrette to replace oil-based salad dressing 1/4 cup for a week

eat one cup of brown rice instead of white rice for dinner

replace one can of fizzy drink a day with sparkling water

eat 2 or more pieces of fruit daily

add one more vegetable to dinner daily

Other:

Required

Stress *

take regular time in nature

learn time management skills

develop problem solving skills. One way to do this is by looking at https://trainingexpress.org.uk/7-steps-to-improve-your-problem-solving-skills/

volunteer for a meaningful cause

undertake regular physical activity

focus on good nutrition for improved emotional wellbeing with a whole food plant-based diet

do mindfulness exercises, meditation, relaxation and time for contemplation

use light therapy, in particular blur light or medical grade light boxes

do abdominal breathing, expressive and creative pursuits such as movement, dance or playing a musical instrument

do massage, tai chi, bibliotherapy and use self-help websites

be involved in spiritual and religious activities

improve frustration tolerance via cognitive behavioural therapy

focus on improving your emotional intelligence

connect more with others: spend time with family, friends or other support groups

Other:

Required

Sleep *

keep the bedroom dark and quiet

keep to a healthy weight

keep bed for sleep and sex only

having a regular bedtime and wake-up time every day

keep well hydrated, especially in the afternoon

have a bath or shower before bed and wear bed-socks if you have cold feet

increase natural daylight exposure

decrease light at night: use only dim light (red tone) for 1 hour before bed and avoid screens

increase daytime physical activity, move every hour

avoid or limit alcohol within 3 hours of bed and other diuretics

try to minimise stress: use active relaxation an hour before bed, a wind-down routine

try to mitigate night-time worrying: use mindfulness based stress reduction, meditation or CBT

Other:

Required

Harmful Substances *

have two consecutive nights a week without alcohol

make your first drink a soft drink

alternate an alcoholic drink with a non-alcoholic one

dilute your alcohol, make it a spritzer

limit alcohol to just 2 drinks a day

identify distraction techniques

call Quitline

attend community stop-smoking services: you may need to consider oral medication

buy over the counter treatment: nicotine replacement

contact alcoholics anonymous

Other:

Required

Social Connections *

initiating contact with others

joining a group that shares your hobby e.g. reading, singing, walking, gardening

popping into the local library, place of worship or coffee shop where there is information about group meetings

volunteering for areas you care about in your community

investing and maintaining strong positive relationships with family and friends

making more time to connect with your partner

developing a new interest

meeting new people

travelling more

Other:

Required

Personalised Action Plan *

- SMART goal (Specific, Measurable, Achievable, Relevant, Timely)

On a scale of 0 to 10 how important is it to you to master this/these areas in the next 3 to 6 months? *

What might increase the level of importance of this change for you? *

On a scale of 0-10, how confident are you that you will master this/ these areas in the next 3-6 months? *

Obstacles impacting confidence to achieve change

What might increase your confidence from this number? *

- accountability, - ideas from them in how they could overcome the obstacle

Follow Up Review Period (months)
*

Follow Up Booking Choice *

will book ad hoc using the website at your convenience at www.hexagon.health/appointments

have prepaid 3 follow up appointments and booked your next one

have prepaid 6 follow up appointments and booked your next one

Other:

Monthly Subscription to Newsletter
*

would

would not

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