Full Name Email Address What do you want to achieve by engaging with the service?* Any ongoing health concerns?* Please provide a list of any regular medication your GP prescribes for you on an ongoing basis* Is there any regular dietary supplements you take* What is your normal diet?* What is your average alcohol consumption—Please choose an option—OtherDailyWeeklyMonthlySpecial OccassionsNever How often do you smoke?—Please choose an option—20+ a day10 - 20 a dayLess than 10 a dayNever How long does it take you to fall asleep?—Please choose an option—2+ hours1-2 hours1 hourUnder an hourImmediately How long do you sleep on average?—Please choose an option—9-10 hours7-8 hours5-6 hours Once asleep, do you sleep well or fitfully?—Please choose an option—FitfullyWell Do you snore?—Please choose an option—I'm not sureNoYes Do you suffer from sleep apnoea?—Please choose an option—YesNoNot sure Stress: can be a massive contributor towards poor physical and/or mental health. Is there anything you’d like to bring to my attention* Exercise: do you have any regular exercise regime (formal or informal - for example regular walking)* Height; weight; waist circumference; neck circumference * Anything else of significance you’d like to raise?*
