Clash of Minds School of Evangelism
Health Assessment Form
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Name
*
First
Last
Email
*
Same as the one you used for the School registration form.
Emergency contact - Partner/Spouse/Friend/Relative
Partner/Spouse/Friend/Relative Name
First
Last
Partner/Spouse/Friend/Relative Email
Partner/Spouse/Friend/Relative Phone
Partner/Spouse/Friend/Relative Gender
Male
Female
Information
Please complete all of the below information, or indicate if you do not have this information available. If you do not measure these parameters at home, please write the last measurement that was tested by a doctor or nurse or pharmacy (or measured by a home-machine).
Height
cm
Weight
kg
BMI current
Pulse at rest
Fitness level
Unfit
Getting Started
Improving
Fit
Athlete
How far can you walk before becoming out of breath?
km
How far can you jog/run before becoming out of breath?
meters
Remedies
Please list all natural remedies and supplements/herbs you use, and indicate how frequently you use them:
Natural remedies and supplements
Medical History
Medications
Write down all the MEDICATIONS you are taking NOW and include dosage and frequency. (Include birth control pills, pain medications, diet hormones, vitamins, minerals, and supplements.)
Stopped medications
Please list all medications you have used during the past year but not using currently (e.g. if you used blood pressure medication and stopped it, you can tell us the name of the medication, and when you last used it.
Allergies
Please list all ALLERGIES and reactions to medications.
Reactions
You can also tell us about reactions you get to other things, e.g. cleaning materials, animals, etc.
Childhood illnesses
List major childhood illnesses and procedures:
Illnesses
What serious ILLNESSES have you had – both physical and mental? Please indicate the date (e.g. stroke, heart attack):
Procedures
What SURGICAL OPERATIONS/PROCEDURES or SERIOUS INJURIES have you had? Please indicate the date.
Blood transfusion
Have you ever had a BLOOD TRANSFUSION? (when)
Vaccinations
Please list all vaccinations and other courses of injections you have received during the past 5 years.
Family History
Illnesses of relatives:
List major illnesses of relatives:
Review of Systems
Health problem - Frequency
Feel free to share details where applicable
Weight gain
In the past only
Rarely
Frequently
No not at all
Weight gain comments
Weight loss (planned)
In the past only
Rarely
Frequently
No not at all
Weight loss (planned) comments
Weight loss (unintentional)
In the past only
Rarely
Frequently
No not at all
Weight loss (unintentional) comments
Fever or night sweats
In the past only
Rarely
Frequently
No not at all
Fever or night sweats comments
Fatigue
In the past only
Rarely
Frequently
No not at all
Fatigue comments
Nutrition
Meal/Snack
Please share with us regarding your general/daily routine
Wake-up snack
Yes
No
Sometimes
Wake-up snack time
Breakfast
Yes
No
Sometimes
Breakfast time
Snack
Yes
No
Sometimes
Snack time
Lunch
Yes
No
Sometimes
Lunch time
Afternoon snack
Yes
No
Sometimes
Afternoon snack time
Supper
Yes
No
Sometimes
Supper time
Snack before bed
Yes
No
Sometimes
Snack before bed time
Wake up in the night and eat something
Yes
No
Sometimes
What do you usually have for breakfast?
What do you usually have for lunch?
What do you usually have for supper?
How frequently do you eat/snack between meals?
General/Daily Exercise Routine
Regular exercise program
Are you on a regular exercise program? If so, what type of exercise do you do?
How often do you exercise?
Never
Once a week
Twice a week
Three times a week
More than 4 times a week
Water
Daily water
How many LITRES of water do you drink on an average day?
Weekly
On average, how many of the following do you drink in a week?
Coffee
cups
Caffeinated tea
cups
Hot chocolate
cups
Cola drinks
cups
Fizzy drinks
cups
Soft drinks
cups
Juices
cups
Beer
glass
Wine
glass
Stronger alcohol
glass
Sunlight
Direct sunlight
Yes
No
Do you get exposed to direct sunlight on a weekly basis?
Sunscreen
Yes
No
Do you usually wear sunscreen when you go into the sun?
Sun on a daily/weekly basis
Weather permitting, how many minutes do you spend in the sun on a daily/weekly basis, and what time of day does this usually happen?
Temperance
Define temperance
How would you define the word temperance?
Unhealthy habits
What do you see as unhealthy habits in your lifestyle?
Expel or eliminate
What would you like to expel or eliminate from your lifestyle?
Stop unhealthy habits
Have you ever tried to stop some unhealthy habits, and failed? If so, please share some details with us of what you did to try and break the habit, and what happened.
Air
Where do you live?
Select
City
Suburb
Rural Area
Farm
Coastal Area
Mountain Area
Desert
Forest
Type of breather
Select
Shallow
Deep
Do you see yourself as a shallow or deep breather?
Pets?
Do you have any pets? Please share details about which kind, and where they sleep and spend their time.
Fresh air
Do you make a conscious effort to expose your lungs to fresh air?
Rest
What is your average bed time?
What is your average wake up time?
Daytime naps
Do you take daytime naps? How long?
Working hours
What are your regular working hours?
Stressful event
Have you recently suffered a stressful event, major life change, or severe loss?
Stress
Yes
No
Not sure
Are you under stress?
Source of stress
What would you say is your strongest source of stress?
Stress affect
How does stress affect you?
Stress duration
How long have you been under stress?
Troublesome thoughts
Do you ever have troublesome thoughts of suicide or feelings of severe depression?
Help
Are there people who can help you and have you gone to them for help?
Trust
Do you have any unresolved issues with
God
Spouse
Child
Parent
Relative
Co-Worker
Friend
Enemy
Other
Unresolved issues comments
Do you mostly feel
Optimistic
Loved
Submitted
Amazed
Happy
Remorse
Discontent
Aggressive
Disapproved
Sad
Religious preference
What is your religious preference?
FURTHER COMMENTS
ANY FURTHER COMMENTS YOU WOULD LIKE TO SHARE WITH US?
Submit