Thrive8Nutrition

Risk Stratification Screening Tool

This risk-stratification screening tool does not substitute advice from an appropriately qualified Medical or Allied Health Professional. It does not promise or warrant against injury or death and no guarantee of protection should result from its use.

Client Details

Section 1A — Identify Current Medical Conditions

Objective: To identify if you present with any known diseases or signs/symptoms of disease.

1

Are you pregnant or breastfeeding?

2

Are you under the age of 16 years old (0–15 years old)?

3

Have you been medically diagnosed with any eating disorder (i.e., anorexia nervosa, anorexia bulimia, binge eating disorder)?

If yes, please indicate below:

4

Have you been diagnosed with diabetes mellitus (i.e., pre-diabetes, type I, type II & gestational diabetes)?

If yes, please indicate below:

5

Have you been diagnosed with coeliac disease?

6

Have you been diagnosed with cancer?

7

Have you been diagnosed with renal disease?

8

Have you ever had bariatric surgery (i.e. gastric sleeve, gastric bypass, lap-band)?

If yes, please indicate below:

9

Have you been diagnosed with any gastrointestinal tract issues? (Diverticulitis, bowel obstructions, IBS, IBD including ulcerative colitis and/or Crohn's disease)

If yes, please indicate below:

10

Have you been diagnosed with thyroid disease (i.e., hypothyroidism or hyperthyroidism)?

If yes, please indicate below:

11

Are you currently taking any prescribed medication for blood pressure, cardiovascular disease or high cholesterol, such as ACE inhibitors, beta blockers, warfarin or statins?

If yes, please list the medication(s) and provide a reason for taking them:

Section 1B — Identify 'At Risk' Factors

Objective: To identify if you present with any risk factors that may require GP clearance.

1

Is your BMI below 18.5 kg/m² or above 40 kg/m²?

BMI = Weight (kg) ÷ (Height (m) × Height (m)). If yes, please provide your BMI below:

2

Have you been diagnosed with any conditions impacting fertility (i.e., polycystic ovarian syndrome, endometriosis)?

If yes, please indicate below:

3

Have you been formally diagnosed with any food allergies and/or intolerances?

If yes, please specify the allergy, diagnostic tool and approximate diagnosis date:

4

Have you been formally diagnosed with a mental health condition in which you are required to take medication?

Section 2 — Identify Possible Food Intolerances / Allergies

Objective: To identify possible food intolerances or allergies.

1

Do you experience bloating regularly?

2

Do you believe you suffer from excessive flatulence?

3

Do you experience irregular bowel motions (i.e., diarrhoea, constipation, sore to pass, abnormal colours, faecal urgency)?

If yes, please provide details on eliminations per day, stool colour, stool abnormalities and formation where possible:

4

Do you believe you suffer from low energy levels?

If yes, please provide more information below:

5

Do you suspect you may have any food allergies and/or intolerances?

If yes, please identify why you think you may have an allergy/intolerance and to what specific food:

Section 3 — Identify Family Health History

Objective: To identify possible chronic health conditions that present within immediate family members.

1

Has an immediate family member (parents or siblings) ever been diagnosed with any of the chronic health conditions outlined in Section 1A?

If yes, please list the medical condition(s) below:

2

If you answered 'yes' above, have you had a health check within the last 12 months and been cleared for that condition?

Additional Notes (if required)