Pre-consultation: Health Screening

First name *

Last name *

Email *

Phone *

Date of birth *

What type of screening are you interested in? *

Select all that apply

General well-person check

Specific concern

Age-related screening

Family history

Returning after illness

Fitness baseline

Pre-insurance medical

Other

What is your age? *

We use this to recommend age-appropriate screening

What is your sex assigned at birth? *

Male

Female

Other

Have you had bowel screening (colonoscopy or FIT test)?

Never

Yes, result normal

Yes, polyps removed

Yes, other findings

If yes to bowel screening, when was it last done?

Have you had mammography (breast screening)?

N/A - not applicable

Never

Yes, normal

Yes, benign findings

Yes, other findings

If yes to mammography, when was it last done?

Have you had cervical screening (smear test)?

N/A - not applicable

Never

Yes, normal

Yes, abnormal results

If yes to cervical screening, when was it last done?

Have you had PSA screening (prostate)?

N/A - not applicable

Never

Yes, normal

Yes, elevated

Have you had skin screening (mole check)?

Never

Yes, normal

Yes, concerning lesions

Have you had your blood pressure checked recently?

No

Yes, normal

Yes, elevated

Yes, high

Have you had your cholesterol checked?

No

Yes, normal

Yes, elevated

Do you have a family history of heart disease or stroke?

No

Yes, in parent

Yes, in sibling

Yes, multiple family members

Have you had diabetes screening (HbA1c or glucose test)?

No

Yes, normal

Yes, prediabetic range

Yes, diabetic range

Do you have risk factors for diabetes (overweight, sedentary, family history)?

No

Yes, one factor

Yes, multiple factors

Do you have any new health concerns or symptoms? *

No

Yes

Do you have any chronic health conditions? *

No

Yes

Are you currently taking any medications? *

No

Yes

Do you have significant family history of disease (cancer, diabetes, heart disease)?

No

Yes

How would you rate your diet?

Excellent

Good

Fair

Poor

How many minutes of physical activity do you do per week?

Aim for 150+ minutes of moderate activity

What is your smoking status?

Never

Ex-smoker (quit >10 years ago)

Ex-smoker (quit <10 years ago)

Current smoker (<10/day)

Current smoker (10+/day)

How many units of alcohol per week?

1 unit = 10ml pure alcohol

How is your sleep quality?

Excellent

Good

Fair

Poor

How many hours of sleep per night (average)?

How would you rate your stress level?

Low

Moderate

High

Very high

Do you use any health wearables or fitness trackers?

No

Yes

What are your main health and wellness goals?

What would you like to improve or maintain?

Is there anything else you'd like to tell us?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Screening Interests

What type of screening are you interested in? -

Basic Details

What is your age? -

What is your sex assigned at birth? -

Previous Screening History

Have you had bowel screening (colonoscopy or FIT test)? -

If yes to bowel screening, when was it last done? -

Have you had mammography (breast screening)? -

If yes to mammography, when was it last done? -

Have you had cervical screening (smear test)? -

If yes to cervical screening, when was it last done? -

Have you had PSA screening (prostate)? -

Have you had skin screening (mole check)? -

Cardiovascular & Metabolic

Have you had your blood pressure checked recently? -

Have you had your cholesterol checked? -

Do you have a family history of heart disease or stroke? -

Have you had diabetes screening (HbA1c or glucose test)? -

Do you have risk factors for diabetes (overweight, sedentary, family history)? -

Current Health

Do you have any new health concerns or symptoms? -

Do you have any chronic health conditions? -

Are you currently taking any medications? -

Do you have significant family history of disease (cancer, diabetes, heart disease)? -

Lifestyle

How would you rate your diet? -

How many minutes of physical activity do you do per week? -

What is your smoking status? -

How many units of alcohol per week? -

How is your sleep quality? -

How many hours of sleep per night (average)? -

How would you rate your stress level? -

Do you use any health wearables or fitness trackers? -

Your Goals

What are your main health and wellness goals? -

Is there anything else you'd like to tell us? -

Upload medical records or test results (optional)

Share any recent blood tests, imaging, or medical records that might be relevant

Click to upload files

Anything else for your doctor?