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.

Do you acknowledge, understand and agree to the conditions above?(Required.)

I agree to the above

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:

Which program are you registering for?(Required.)

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

What is your first and last name?(Required.)

What is your email address? (Required.)

What is your phone number?(Required.)

Do you identify as a person with a disability?(Required.)

Yes

What Council area do you live in?(Required.)

What is your gender?(Required.)

Male

Female

Other

Please provide your emergency contact details(Required.)

Emergency contact name

Emergency contact email address

Emergency contact phone number

Which of the following categories best describes your employment status?(Required.)

Unemployed (not currently working)

Unemployed (not able to work)

Employed, part-time

Employed, full-time

Other (please specify)

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

Less than or equal to $65k per year

More than $65k per year

Rather not say

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

Please provide the details of your Psychologist, Psychiatrist, GP or support person.(Required.)

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)

What are you currently experiencing?(Required.)

Depression

Anxiety

Both

Neither

Have you received a formal diagnosis?(Required.)

Yes

Are you currently taking a medication for your mental health?

Yes

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.(Required.)

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:(Required.)

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.

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?

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.(Required.)

I understand

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?(Required.)

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

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?(Required.)

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

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?(Required.)

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

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.(Required.)

What other support are you currently receiving for your mental health?
Please select as many as apply(Required.)

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.