2022 Mood Active Registration Survey

Welcome to Mood Active!

We run exercise programs designed to improve your mental health.

As a charity our programs are either free or low cost.

We ask all participants to complete a registration survey so we can ensure it is safe for you to join our programs. We also ask some questions about your current physical and mental health.

The survey takes about 15 minutes to complete and all questions must be answered to secure your spot in the program.

4 Week Wellbeing Workout
In return for our free programs, we ask that you commit to completing a post program survey and 3 month follow survey up. This helps us show our funding partners the effectiveness of the program on your overall wellbeing. All data is stored in a secure database and only shared with authorized personnel including Trainers. Your mood and fitness results with also be shared anonymously with our funding partners and is de-identified (no names)

The data collected from these surveys is then aggregated to look at patterns and themes and is critical in ensuring that we are able to continue to run our programs.

Casual Program

In return for our low cost programs, we ask that you commit to completing a 3 month follow survey up. This helps us show our funding partners the effectiveness of the program on your overall wellbeing. All data is stored in a secure database and only shared with authorized personnel including Trainers. Your mood and fitness results with also be shared anonymously with our funding partners and is de-identified (no names)

The data collected from these surveys is then aggregated to look at patterns and themes and is critical in ensuring that we are able to continue to run our programs.

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* Do you acknowledge, understand and agree to the conditions above?

I agree to the above

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* If you are under 18, please have your parent or guardian fill in this survey with you and provide their full name, email address and mobile number.
In doing so, they confirm that-
The information they provide regarding their child’s health is correct, to the best of their knowledge
They will inform the Registered Exercise Professional of any changes to their child’s health immediately
They have been informed and understand the service that is to be provided and give permission for their child to commence the exercise program

Parent /Guardian name:

Email address:

Mobile number:

Relationship to participant:

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* Which program are you registering for?

Thursdays 10-1pm October 2022 Briars Face to Face 4 Week Wellbeing Workout

Fridays 10-1pm November Burwood Face to Face 4 Week Wellbeing Workout

Another program in 2023

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* What is your first and last name?

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* What is your email address?

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* What is your phone number?

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* What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* Do you identify as a person with a disability?

Yes

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* What Council area do you live in?

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* What is your gender?

Male

Female

Other

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* Please provide your emergency contact details

Emergency contact name

Emergency contact email address

Emergency contact phone number

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* Which of the following categories best describes your employment status?

Unemployed (not currently working)

Unemployed (not able to work)

Employed, part-time

Employed, full-time

Other (please specify)

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* Please select the description that best describes your income (before tax)?

Less than or equal to $65k per year

More than $65k per year

Rather not say

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* How did you first find out about Mood Active?

Community Service Provider (please include name below)

Facebook

GP (please include name below)

Instagram

Mood Active website

Mood Active mentioned or shown in newspaper/article/radio

Online Directory (please include directory name below)

Psychologist (please include name below)

Psychiatrist (please include name below)

Word of mouth - friend or family member recommended it

Other

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* If applicable, please include the name of the referrer, directory or other source here:

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* Please provide the details of your Psychologist, Psychiatrist, GP or support person.

Support provider name/s and name of their practice / medical centre

Contact details (optional, by providing their email or phone number you give us permission to contact them ONLY if the need arises)

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* What are you currently experiencing?

Depression

Anxiety

Both

Neither

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* Have you received a formal diagnosis?

Yes

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* What is your diagnosis (you can select more than one):

Bipolar I

Bipolar II

Anxiety

Depression

None of the above/Other (please specify)

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* Are you currently taking a medication for your mental health?

Yes

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* In order for us to best understand you and your body, please let us know what medication you are taking and if you have any side effects.

Medication works differently for different people, and it is important for your safety that our trainers can modify exercises for you, if you experience medication side effects.

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* This section has a series of questions about your feelings, emotions and behaviours over this past week.

For each of the statements below, please indicate how often the statement applied to you over the past week

0 = Did not apply to me at all
1 = Applied to me to some degree, or some of the time
2 = Applied to me a considerable part of the time
3 = Applied to me very much, or most of the time

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* Coping with stress
Please indicate how true each statement has have been for you during the past week.

0 = not true/rarely true
1 = sometimes true
2 = mostly true/always true

	0 = not true/rarely true	1 = sometimes true	2 = mostly true/always true
I had thoughts about killing myself	I had thoughts about killing myself 0 = not true/rarely true	I had thoughts about killing myself 1 = sometimes true	I had thoughts about killing myself 2 = mostly true/always true
I was sleeping too much	I was sleeping too much 0 = not true/rarely true	I was sleeping too much 1 = sometimes true	I was sleeping too much 2 = mostly true/always true
I could keep myself from feeling depressed	I could keep myself from feeling depressed 0 = not true/rarely true	I could keep myself from feeling depressed 1 = sometimes true	I could keep myself from feeling depressed 2 = mostly true/always true
I wished I was dead	I wished I was dead 0 = not true/rarely true	I wished I was dead 1 = sometimes true	I wished I was dead 2 = mostly true/always true
My energy level was low	My energy level was low 0 = not true/rarely true	My energy level was low 1 = sometimes true	My energy level was low 2 = mostly true/always true
I had difficulty sleeping	I had difficulty sleeping 0 = not true/rarely true	I had difficulty sleeping 1 = sometimes true	I had difficulty sleeping 2 = mostly true/always true
I am able to bounce back from stressful conversations	I am able to bounce back from stressful conversations 0 = not true/rarely true	I am able to bounce back from stressful conversations 1 = sometimes true	I am able to bounce back from stressful conversations 2 = mostly true/always true
I coped well with the normal stresses and hassles of life	I coped well with the normal stresses and hassles of life 0 = not true/rarely true	I coped well with the normal stresses and hassles of life 1 = sometimes true	I coped well with the normal stresses and hassles of life 2 = mostly true/always true
I had a sense of dread or impending doom	I had a sense of dread or impending doom 0 = not true/rarely true	I had a sense of dread or impending doom 1 = sometimes true	I had a sense of dread or impending doom 2 = mostly true/always true
I felt 'on edge'	I felt 'on edge' 0 = not true/rarely true	I felt 'on edge' 1 = sometimes true	I felt 'on edge' 2 = mostly true/always true
I got irritated easily	I got irritated easily 0 = not true/rarely true	I got irritated easily 1 = sometimes true	I got irritated easily 2 = mostly true/always true
I felt anxious	I felt anxious 0 = not true/rarely true	I felt anxious 1 = sometimes true	I felt anxious 2 = mostly true/always true
My appetite was poor	My appetite was poor 0 = not true/rarely true	My appetite was poor 1 = sometimes true	My appetite was poor 2 = mostly true/always true
I worried excessively	I worried excessively 0 = not true/rarely true	I worried excessively 1 = sometimes true	I worried excessively 2 = mostly true/always true
My appetite was greater than usual	My appetite was greater than usual 0 = not true/rarely true	My appetite was greater than usual 1 = sometimes true	My appetite was greater than usual 2 = mostly true/always true
I felt sad or depressed	I felt sad or depressed 0 = not true/rarely true	I felt sad or depressed 1 = sometimes true	I felt sad or depressed 2 = mostly true/always true
I had difficulty making decisions	I had difficulty making decisions 0 = not true/rarely true	I had difficulty making decisions 1 = sometimes true	I had difficulty making decisions 2 = mostly true/always true
I felt guilty	I felt guilty 0 = not true/rarely true	I felt guilty 1 = sometimes true	I felt guilty 2 = mostly true/always true
I had problems concentrating	I had problems concentrating 0 = not true/rarely true	I had problems concentrating 1 = sometimes true	I had problems concentrating 2 = mostly true/always true
I thought I was a failure	I thought I was a failure 0 = not true/rarely true	I thought I was a failure 1 = sometimes true	I thought I was a failure 2 = mostly true/always true
I was not interested in the things I usually enjoy	I was not interested in the things I usually enjoy 0 = not true/rarely true	I was not interested in the things I usually enjoy 1 = sometimes true	I was not interested in the things I usually enjoy 2 = mostly true/always true

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* General Well-Being
Please indicate how true each statement have been for you during the past week.

0 = not true/rarely true
1 = sometimes true
2 = mostly true/always true

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* Do you have any physical concerns that might prevent you from doing exercise? If you have any concerns please contact your doctor.
To ensure this program is suitable for you, please review the below carefully and check the box if your response is Yes to any of the questions below:

Has your doctor ever told you that you have a heart condition, or have you ever suffered a stroke?

Do you ever experience unexplained pains in your chest at rest or during physical activity/ exercise?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Is your doctor currently prescribing you medication for blood pressure or a heart condition?

If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months?

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

None of the above.

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* Can you give us some more information about any of the items you ticked above? For example, if you are on any medication, can you please list the medication?

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* There are health risks involved with increasing intensity of exercise, especially if you have done no exercise for a long time. This risk is increased if you have answered "Yes" to ANY of the above.

We may seek written approval from your doctor that you are fit to exercise before commencing. Our trainers are not medically qualified to determine if you can or cannot exercise so if you do have any concerns at all, we urge you to seek advice from your medical practitioner.

If you have indicated "Yes" to any of the above, our Program Manager will be in touch to discuss this further.

I understand

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* Exercise Habits
In this section we are interested in finding out about the kinds of physical exercise that you do as part of your everyday life. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

Vigorous exercise
Think about all the vigorous physical exercise that you did in the last 7 days. Vigorous refers to activities that take hard physical effort and make you breathe rapidly with a high heart rate (ie. 70-85% of your maximum heart rate, 7 out of 10 effort, hard to talk). The type of activity will vary for everyone as it depends on your weight, physical health and age e.g walking or running could be vigorous depending on you. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do vigorous exercise?

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you did vigorous exercise.

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* Moderate Exercise
Think about all the moderate exercise that you did in the last 7 days. Moderate refers to activities that take moderate physical effort and make you breathe somewhat harder than normal with an increased heart rate (ie 50-70% of maximise heart rate, 5-7 out of 10 effort, can hold a basic conversation). Again the type of activity will vary depending on you. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do moderate exercise?

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you did moderate exercise.

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* Walking
Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you have done solely for recreation, sport, exercise, or leisure.

During the last 7 days, on how many days did you walk for at least 10 minutes?

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you walked.

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* Sitting
The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

Thinking about an average weekday from the last 7 days...
How many hours did you spend sitting on an average weekday?
Please just give your answer for one day, and not the entire week. If you aren't sure, just make your best guess.

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* What other support are you currently receiving for your mental health?
Please select as many as apply

No other support

Mental health medication

Psychological services (e.g. psychologist, counsellor)

Dietitian

Natural therapies

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* Thank you for taking the time to complete the survey.

You will soon receive a calendar invitation confirming your enrolment. Please ensure you dress in active wear and bring a water bottle. We look forward to meeting you at the first session!

If you have any questions in the meantime, visit our website at www.moodactive.org.au, drop us an email at info@moodactive.org.au or call us on 0412 190 842.

	0 = Did not apply to me at all	1 = Applied to me to some degree, or some of the ti	2 = Applied to me a considerable part of the time	3 = Applied to me very much, or most of the time
I felt that I was using a lot of nervous energy	I felt that I was using a lot of nervous energy 0 = Did not apply to me at all	I felt that I was using a lot of nervous energy 1 = Applied to me to some degree, or some of the ti	I felt that I was using a lot of nervous energy 2 = Applied to me a considerable part of the time	I felt that I was using a lot of nervous energy 3 = Applied to me very much, or most of the time
I felt like I wasn't much of a person	I felt like I wasn't much of a person 0 = Did not apply to me at all	I felt like I wasn't much of a person 1 = Applied to me to some degree, or some of the ti	I felt like I wasn't much of a person 2 = Applied to me a considerable part of the time	I felt like I wasn't much of a person 3 = Applied to me very much, or most of the time
I experienced difficulty breathing(e.g. excessively rapid breathing, in the absence of physical exertion)	I experienced difficulty breathing(e.g. excessively rapid breathing, in the absence of physical exertion) 0 = Did not apply to me at all	I experienced difficulty breathing(e.g. excessively rapid breathing, in the absence of physical exertion) 1 = Applied to me to some degree, or some of the ti	I experienced difficulty breathing(e.g. excessively rapid breathing, in the absence of physical exertion) 2 = Applied to me a considerable part of the time	I experienced difficulty breathing(e.g. excessively rapid breathing, in the absence of physical exertion) 3 = Applied to me very much, or most of the time
I was aware of dryness of my mouth	I was aware of dryness of my mouth 0 = Did not apply to me at all	I was aware of dryness of my mouth 1 = Applied to me to some degree, or some of the ti	I was aware of dryness of my mouth 2 = Applied to me a considerable part of the time	I was aware of dryness of my mouth 3 = Applied to me very much, or most of the time
I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)	I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) 0 = Did not apply to me at all	I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) 1 = Applied to me to some degree, or some of the ti	I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) 2 = Applied to me a considerable part of the time	I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) 3 = Applied to me very much, or most of the time
I tended to over-react to situations	I tended to over-react to situations 0 = Did not apply to me at all	I tended to over-react to situations 1 = Applied to me to some degree, or some of the ti	I tended to over-react to situations 2 = Applied to me a considerable part of the time	I tended to over-react to situations 3 = Applied to me very much, or most of the time
I felt I was rather touchy	I felt I was rather touchy 0 = Did not apply to me at all	I felt I was rather touchy 1 = Applied to me to some degree, or some of the ti	I felt I was rather touchy 2 = Applied to me a considerable part of the time	I felt I was rather touchy 3 = Applied to me very much, or most of the time
I couldn't seem to experience any positive feelings at all	I couldn't seem to experience any positive feelings at all 0 = Did not apply to me at all	I couldn't seem to experience any positive feelings at all 1 = Applied to me to some degree, or some of the ti	I couldn't seem to experience any positive feelings at all 2 = Applied to me a considerable part of the time	I couldn't seem to experience any positive feelings at all 3 = Applied to me very much, or most of the time
I found it hard to wind down	I found it hard to wind down 0 = Did not apply to me at all	I found it hard to wind down 1 = Applied to me to some degree, or some of the ti	I found it hard to wind down 2 = Applied to me a considerable part of the time	I found it hard to wind down 3 = Applied to me very much, or most of the time
I experienced trembling (eg. in the hands)	I experienced trembling (eg. in the hands) 0 = Did not apply to me at all	I experienced trembling (eg. in the hands) 1 = Applied to me to some degree, or some of the ti	I experienced trembling (eg. in the hands) 2 = Applied to me a considerable part of the time	I experienced trembling (eg. in the hands) 3 = Applied to me very much, or most of the time
I found it difficult to work up the initiative to do things	I found it difficult to work up the initiative to do things 0 = Did not apply to me at all	I found it difficult to work up the initiative to do things 1 = Applied to me to some degree, or some of the ti	I found it difficult to work up the initiative to do things 2 = Applied to me a considerable part of the time	I found it difficult to work up the initiative to do things 3 = Applied to me very much, or most of the time
I felt that life was meaningless	I felt that life was meaningless 0 = Did not apply to me at all	I felt that life was meaningless 1 = Applied to me to some degree, or some of the ti	I felt that life was meaningless 2 = Applied to me a considerable part of the time	I felt that life was meaningless 3 = Applied to me very much, or most of the time
I felt close to panic	I felt close to panic 0 = Did not apply to me at all	I felt close to panic 1 = Applied to me to some degree, or some of the ti	I felt close to panic 2 = Applied to me a considerable part of the time	I felt close to panic 3 = Applied to me very much, or most of the time
I was unable to become enthusiastic about anything	I was unable to become enthusiastic about anything 0 = Did not apply to me at all	I was unable to become enthusiastic about anything 1 = Applied to me to some degree, or some of the ti	I was unable to become enthusiastic about anything 2 = Applied to me a considerable part of the time	I was unable to become enthusiastic about anything 3 = Applied to me very much, or most of the time
I found it difficult to relax	I found it difficult to relax 0 = Did not apply to me at all	I found it difficult to relax 1 = Applied to me to some degree, or some of the ti	I found it difficult to relax 2 = Applied to me a considerable part of the time	I found it difficult to relax 3 = Applied to me very much, or most of the time
I found I was intolerant of anything that kept me from doing what I was doing	I found I was intolerant of anything that kept me from doing what I was doing 0 = Did not apply to me at all	I found I was intolerant of anything that kept me from doing what I was doing 1 = Applied to me to some degree, or some of the ti	I found I was intolerant of anything that kept me from doing what I was doing 2 = Applied to me a considerable part of the time	I found I was intolerant of anything that kept me from doing what I was doing 3 = Applied to me very much, or most of the time
I felt that I had nothing to look forward to	I felt that I had nothing to look forward to 0 = Did not apply to me at all	I felt that I had nothing to look forward to 1 = Applied to me to some degree, or some of the ti	I felt that I had nothing to look forward to 2 = Applied to me a considerable part of the time	I felt that I had nothing to look forward to 3 = Applied to me very much, or most of the time
I felt downhearted and blue	I felt downhearted and blue 0 = Did not apply to me at all	I felt downhearted and blue 1 = Applied to me to some degree, or some of the ti	I felt downhearted and blue 2 = Applied to me a considerable part of the time	I felt downhearted and blue 3 = Applied to me very much, or most of the time
I felt scared without any good reason	I felt scared without any good reason 0 = Did not apply to me at all	I felt scared without any good reason 1 = Applied to me to some degree, or some of the ti	I felt scared without any good reason 2 = Applied to me a considerable part of the time	I felt scared without any good reason 3 = Applied to me very much, or most of the time
I found myself getting agitated	I found myself getting agitated 0 = Did not apply to me at all	I found myself getting agitated 1 = Applied to me to some degree, or some of the ti	I found myself getting agitated 2 = Applied to me a considerable part of the time	I found myself getting agitated 3 = Applied to me very much, or most of the time
I was worried about situations in which I might panic and make a fool of myself	I was worried about situations in which I might panic and make a fool of myself 0 = Did not apply to me at all	I was worried about situations in which I might panic and make a fool of myself 1 = Applied to me to some degree, or some of the ti	I was worried about situations in which I might panic and make a fool of myself 2 = Applied to me a considerable part of the time	I was worried about situations in which I might panic and make a fool of myself 3 = Applied to me very much, or most of the time

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* Do you acknowledge, understand and agree to the conditions above?

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* Which program are you registering for?

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* What is your first and last name?

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* What is your email address?

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* What is your phone number?

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* What is your age?

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* Do you identify as a person with a disability?

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* What Council area do you live in?

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* What is your gender?

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* Please provide your emergency contact details

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* Which of the following categories best describes your employment status?

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* Please select the description that best describes your income (before tax)?

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* How did you first find out about Mood Active?

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* If applicable, please include the name of the referrer, directory or other source here:

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* Please provide the details of your Psychologist, Psychiatrist, GP or support person.

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* What are you currently experiencing?

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* Have you received a formal diagnosis?

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* What is your diagnosis (you can select more than one):

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* Are you currently taking a medication for your mental health?

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* Coping with stress Please indicate how true each statement has have been for you during the past week.0 = not true/rarely true1 = sometimes true2 = mostly true/always true

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* General Well-BeingPlease indicate how true each statement have been for you during the past week.0 = not true/rarely true1 = sometimes true2 = mostly true/always true

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* Do you have any physical concerns that might prevent you from doing exercise? If you have any concerns please contact your doctor. To ensure this program is suitable for you, please review the below carefully and check the box if your response is Yes to any of the questions below:

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* Can you give us some more information about any of the items you ticked above? For example, if you are on any medication, can you please list the medication?

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you did vigorous exercise.

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you did moderate exercise.

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* Now think in terms of minutes. Over the course of the week, estimate how many minutes in total you walked.

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* What other support are you currently receiving for your mental health?Please select as many as apply

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* Coping with stress
Please indicate how true each statement has have been for you during the past week.

0 = not true/rarely true
1 = sometimes true
2 = mostly true/always true

* General Well-Being
Please indicate how true each statement have been for you during the past week.

0 = not true/rarely true
1 = sometimes true
2 = mostly true/always true

* Do you have any physical concerns that might prevent you from doing exercise? If you have any concerns please contact your doctor.
To ensure this program is suitable for you, please review the below carefully and check the box if your response is Yes to any of the questions below:

* What other support are you currently receiving for your mental health?
Please select as many as apply