Lifestyle Medicine Patient Questionnaire

  • This information is received by Aspiring Medical via email. Aspiring Medical maintain a high level of security against phishing attacks or otherwise, however cannot guarantee full security against interception. If you do not feel comfortable sending this information via email, please do not hesitate to call our friendly reception team on 03 443 0725. 
  • Please complete this questionnaire at least 24 hours prior to your first lifestyle medicine consultation. 

Medical History

Health and Sleep




Standard Serving of Fruit

Standard Serving Size Fruit

Standard Serving of Vegetables

Standard Serving Size Veges v2

Mental Health

Substance Use - Smoking

Substance Use - Alcohol and Drugs

Standard Drink

Standard Drink Alcohol

Are you ready to change?

How important is it to you that you change?

Scale How important is it for you to change.

How confident are you that you could make this change?

Scale How confident are you that you could change

Thank-you for taking the time to complete this questionnaire.