Assessment Questionnaire

The Healthy Mind, Healthy Body Program (HMHB) is a 12-week multicomponent lifestyle intervention program involving weekly participation in a 3 hour session that includes exercise, brain training and educational/practice-based service at Wolper. Each week participants will receive an individualised exercise session, consisting of aerobic, strength and balance exercises, computer-based cognitive training and educational/practice-based sessions such as nutrition and mindfulness practice.

This program is designed to encourage healthy lifestyle changes that aim to reduce cardiovascular risk factors, maintain cognitive ability, and improve quality of life for older adults at risk of functional decline.

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* 1. Name

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* 2. Email

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* 3. Best contact number

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* 4. Date of Birth

Date

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* 5. Where are you living?

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* 6. Have you or your loved ones noticed any change in your thinking or memory?

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* 7. Have you had a diagnosis of dementia?

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* 8. Are you able to exercise continuously for more than 15 minutes?

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* 9. If you are able to exercise continuously for 15 minutes or more, choose the type of activity you complete regularly. Select all that apply.

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* 10. Are you able to complete all your day-to-day tasks?
Select all that apply

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* 11. Are you able to attend Wolper, every Wednesday for three-hour sessions for 12 weeks?

Please note that there will be appointments in the week prior to and following for assessments by the treating team to assist in designing your program.

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* 12. Are you willing to complete program-related tasks at home a minimum of three times per week (about 6–7 hours total)?
You’ll also be asked to keep a journal of these activities.

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* 13. Are you happy to participate in research associated with the program?

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* 14. Have you discussed this with your GP and are they able to provide a referral to the clinic if needed?

 
 50% of survey complete.

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