Suitability Questionnaire

Your name*

Have you made any changes to your health or lifestyle since your diagnosis?*

Yes - definitely

No - not at all

Yes - a little bit

What supports do you have?*

I live with someone who would support me on this progam

I have family or friends who I don't live with who would support me on this program

How flexible are you with food?

Not at all - I wouldn't change anything even if there was good scientific evidence that I should.

I would reluctantly change the food I eat only if there was good scientific evidence.

I am reasonably flexible with food that I eat, especially if there is a good scientific reason.

No problem - tell me what to eat (and why!) and I'll give it a go.

How active are you?*

I engage in physical activity less than once a week

I engage in physical activity at least once a week

I am active every day

Would you make an effort to add some personalised exercises to your lifestyle?*

Yes

Do you see any doctors in Australia?*

I have a regular GP

I have a geriatrician

I see another specialist/other specialists

None regularly

Do you think that the ReCODE program would be quick and easy?*

Yes

Please give me any more information on the above you would like to share.

Please fill out this form from the point of view of the person considering participating in the ReCODE program.

Email: sarah@doctorsarahstephens.com.au

Phone: (02) 6278 3488

Address: 15 Scullin Place, Scullin ACT