Your Wellness Baseline Questionnaire
© Future Wellness Group Holdings Pty Ltd
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Quick Guide:

We understand the importance of privacy and the trust you place in us when you complete our digital assessment, LifeCheck.

We have taken several measures to ensure the confidentiality of your personal data, including the use of a unique alphanumeric sequence to identify your answers and anonymise your information.

Should you have any concerns or questions, please don't hesitate to reach out to your practitioner or email us at support@futurewellnessgroup.com.

As you begin the questionnaire, you will be asked to provide some basic body markers such as height, weight, pulse rate, and blood pressure. It may be helpful to scroll through the questions first before starting to ensure you have all the information you need.

Next steps are: your answers are analysed; a baseline wellbeing score is calculated; a report is generated and emailed directly to you. The report will be reviewed by your practitioner, who will provide comments and support materials at your scheduled consultation.

The information in the report will be valuable in helping you to identify, maintain, and/or improve your overall well-being, and we are here to support you in that journey.

No Information collected will be provided to or sold to third parties.

Your Email Address *
Your Organisation / Practitioner Name *
Year of Birth (Note YYYY only) *
Birth Gender *
Ethnicity *
Family history with Diabetes, Heart Attack, Stroke  (please check all that apply) *
Required
Family History with Cancer (please check all that apply) *
Required
Have you been diagnosed with Gestational Diabetes
Clear selection
Pregnancies (if relevant) number only
Locality (where you live) - Please provide your post or zip code, number only, like this - 2001 or 90210 or EC *
What is your height (barefoot) - Centimetres  (whole number ONLY) *
What is your body weight - Kilograms or Pounds (whole number ONLY) *
What is your blood pressure (if available) - like this 120/80 Ensure back slash between numbers OR LEAVE BLANK
What is your resting heart/pulse rate number only (if available) OTHERWISE LEAVE BLANK
Your Glucose Level as mmol/l (if available) OTHERWISE LEAVE BLANK
Heart and/or Cholesterol Medication
 *
Vitamin D:
Do you spend 30 minutes or more in the sunshine/outdoors every day ?
 *
Have you had COVID-19 or one of its variants ? *
Do you get sick (a day off work/school) more than 4 times per year ?
 *
Alcohol Consumption, number only of drinks per day, no words *
Smoking or Vaping, number of times per day whole number only *
Hydration: *
Sleep *
Nutrition (check all that apply) *
Required
Weekly Exercise, number only of minutes per week, no words
 *
Over the last two weeks, how often have you felt nervous, anxious or on edge
 *
Over the last two weeks, have you felt that you could not stop or control worrying about situations
 *
Over the last two weeks, have you felt down, depressed or hopeless
 *
Over the last two weeks, did you have little interest or pleasure in doing things
 *
How do you view your Life *
What are your energy levels ?
 *
Thank you for participating, we hope you enjoy long term health and wellbeing. Expect your report generally within 4 to 6 hours post review
Post:  If you would like to speak with a support practitioner in the next few days, please leave us a contact phone number or an email address where we can reach you in confidence.
Disclaimer: 
Future Wellness Group Holdings Pty Ltd does not provide medical advice, diagnosis, or treatment.
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