Healthy Mind Healthy Body

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 (Required.)

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2. Email (Required.)

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3. Best contact number (Required.)

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4. Date of Birth (Required.)

Date

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5. Where are you living? (Required.)

Own home/apartment

Retirement village

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6. Have you or your loved ones noticed any change in your thinking or memory? (Required.)

Yes

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7. Have you had a diagnosis of dementia? (Required.)

Yes

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8. Are you able to exercise continuously for more than 15 minutes? (Required.)

Yes

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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. (Required.)

Walking (treadmill or outdoor)

Climbing 5 or more flights of stairs

Stationary bicycle

Walking up a hill without a rest

Swimming laps (pool or ocean)

Community exercise class

Not applicable to me

Other (please specify)

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

Work

Finances

Driving

Housework

Cooking

Looking after grandchildren

None of the above

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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. (Required.)

Yes

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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. (Required.)

Yes

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13. Are you happy to participate in research associated with the program? (Required.)

Yes

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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? (Required.)

Yes

50% of survey complete.

Healthy Mind Healthy Body

Assessment Questionnaire

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* 1. Name (Required.)

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* 2. Email (Required.)

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* 3. Best contact number (Required.)

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* 4. Date of Birth (Required.)

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* 5. Where are you living? (Required.)

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

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* 7. Have you had a diagnosis of dementia? (Required.)

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

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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. (Required.)

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

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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. (Required.)

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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. (Required.)

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

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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? (Required.)

1. Name (Required.)

2. Email (Required.)

3. Best contact number (Required.)

4. Date of Birth (Required.)

5. Where are you living? (Required.)

6. Have you or your loved ones noticed any change in your thinking or memory? (Required.)

7. Have you had a diagnosis of dementia? (Required.)

8. Are you able to exercise continuously for more than 15 minutes? (Required.)

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. (Required.)

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

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. (Required.)

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. (Required.)

13. Are you happy to participate in research associated with the program? (Required.)

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