PREVIVA HEALTH ASSESSMENT

Tell us about your health.

Your answers help your doctor understand your health, medical and family history, lifestyle and what you would like to focus on. Most people finish in around 10 to 15 minutes.

About you

A few details to get started.

Full name *

Date of birth *

Assigned sex at birth

Height

Weight

What do you do for work?

Average hours worked each week

Hours spent sitting each day

What prompted you to book?

I want a thorough understanding of my health I want to improve my health or performance I have symptoms or changes I want to understand I feel well and want to stay that way I want to understand my future health risks Something else

Medical history

Tell us about your health so far.

Have you ever been diagnosed with any of the following?

Heart disease High blood pressure High cholesterol Stroke Atrial fibrillation Diabetes Prediabetes Fatty liver disease Kidney disease Thyroid disease Asthma Sleep apnoea Cancer Skin cancer Osteoporosis Autoimmune disease Depression Anxiety ADHD None of the above

Are you currently experiencing any of these?

Fatigue Brain fog Poor concentration Low libido Weight gain Weight loss Headaches Reduced exercise tolerance Frequent infections Night sweats Excessive thirst Frequent urination None of the above

Any other conditions, operations or procedures?

Medications & supplements

Include prescription medicines, over the counter products and supplements.

Current medications

Vitamins, supplements or other health products

Allergies

Family history

Family history can meaningfully change how we assess your risk. Add the relative and approximate age at diagnosis where you can.

Which conditions run in your family?

Heart disease Stroke Diabetes High cholesterol High blood pressure Autoimmune disease Dementia Osteoporosis None of the above

Family cancers

Breast cancer Ovarian cancer Prostate cancer Bowel cancer Melanoma Pancreatic cancer Other cancer None of the above

Has any family member had genetic testing for an inherited condition?

No Yes Unsure

Heart health

Symptoms, previous testing and cardiovascular risk.

Have you experienced any of these?

Chest pain Palpitations Shortness of breath Collapse or blackout Dizziness Swollen legs None of the above

Past heart tests

ECG Stress test Echocardiogram CT calcium score Angiogram Heart monitor None of the above

Sleep & energy

How you sleep, recover and feel through the day.

Average sleep each night

Sleep quality

Tick anything that applies

Slow to fall asleep Wake unrefreshed Snoring Pauses in breathing Daytime sleepiness Shift work Morning headaches Waking frequently overnight None of the above

How would you rate your energy levels?

Lifestyle

Your daily routine, stress, smoking and alcohol.

How active are you outside of exercise?

Current stress level

What contributes most to your stress?

Work Finances Relationships Health Family Sleep Time pressure Other None of the above

Smoking

Standard alcoholic drinks per week

Exercise

Your current movement and what you are working towards.

How would you rate your current fitness?

What do you do each week?

Resistance or weights Cardio Sport Walking Yoga or mobility Little or none

Sessions per week

Daily steps, if known

Exercise goals

Nutrition

No judgement. We just want a useful baseline.

A typical day of eating

Water per day

Coffee per day

Food intolerances, previous diets or biggest nutritional challenge

Skin cancer

A key screening domain in Australia.

Tick anything that applies

Previous skin cancer Previous melanoma Family history of melanoma History of severe sunburns Used a solarium Many moles Fair skin or burns easily Outdoor occupation None of the above

Have you noticed a new or changing spot or mole?

Do you have regular skin checks?

Reproductive & hormonal health

This section is tailored to you based on the sex at birth selected earlier.

Where are you currently in your reproductive life?

Having regular periods Periods are becoming irregular Perimenopausal Postmenopausal Pregnant Breastfeeding Unsure

Age when periods started

Date of last menstrual period

How would you describe your periods?

Regular Irregular Heavy Painful Very light I do not currently have periods

Are you experiencing any of the following?

Hot flushes Night sweats Vaginal dryness Pain with sex Reduced libido Mood changes Brain fog Sleep changes Hair thinning Acne or increased facial hair None of the above

Pregnancy and fertility

Planning pregnancy within 12 months Trying to conceive now Previous fertility testing Previous fertility treatment Previous miscarriage Previous pregnancy complication No current fertility concerns

Number of previous pregnancies

Number of births

Have you ever been diagnosed with any of the following?

PCOS Endometriosis Fibroids Ovarian cysts Early menopause / ovarian insufficiency Gestational diabetes Pre-eclampsia None of the above

Contraception or hormone therapy

Combined oral contraceptive pill Progesterone only pill Hormonal IUD Copper IUD Implant or injection Menopausal hormone therapy None

Women’s health screening

Cervical screening is up to date Have had a mammogram before Have had a breast ultrasound or MRI before Have noticed a breast lump, skin change or nipple discharge

Anything else you would like your doctor to know about your periods, hormones, fertility, pregnancy history, menopause or sexual health?

Are you experiencing any of the following?

Reduced libido Erectile dysfunction Reduced morning erections Fatigue Reduced strength or muscle mass Low motivation Difficulty concentrating Mood changes or irritability Reduced shaving frequency or body hair Breast tenderness or enlargement None of the above

Fertility

Planning to conceive within 12 months Currently trying to conceive Previous fertility testing Previous fertility treatment Known low sperm count or fertility issue No current fertility concerns

Have you ever had any of the following?

Undescended testicle Testicular injury or surgery Varicocele Testicular infection Prostate condition Testicular or prostate cancer None of the above

Urinary or prostate symptoms

Weak urinary stream Difficulty starting Urinary frequency Urgency Getting up at night to urinate Feeling of incomplete emptying Blood in urine or semen None of the above

Have you ever had a PSA blood test?

Testosterone, anabolic agents or performance products

This is confidential and helps your doctor interpret your results and monitor your health safely.

Testosterone replacement therapy Anabolic steroids SARMs Peptides hCG Other hormone or performance product None

If relevant, tell us what you use, the dose, how often and for how long

Anything else you would like your doctor to know about your hormones, fertility, sexual health, testicular health or prostate health?

Anything relevant to your reproductive, sexual or hormonal health that you would like your doctor to know?

What is limiting your health?

Understanding what gets in the way helps us build a plan that fits your life.

Time Motivation Knowledge Money Injury or pain Stress Sleep Work demands Family demands Nothing in particular

What feels like the biggest barrier?

Your goals

The final part: what you want from the next 12 months.

What are the three biggest improvements you would like to see?

Lose weight Improve energy Improve sleep Reduce cardiovascular risk Build muscle Reduce body fat Understand hormone health Improve long term health Understand my health Reduce my risk of diabetes Improve mental wellbeing Improve sexual health

How ready are you to make changes?

If Previva was a success for you in 12 months, what would be different about your health?

Your privacy
Previva collects the personal and health information you provide to understand your health history, prepare for your assessment and provide healthcare services. Please review Previva’s Privacy Policy before submitting this form.

I acknowledge that I have read the Privacy Policy and understand how my information will be handled.

THANK YOU

Your assessment has been completed.

Thank you. Your Previva doctor will review your questionnaire before your assessment.