Healthier Parents Program EOI

Personal details are collected but not disclosed to third parties (beyond provider for insurance, emergency and/or attendance purposes).

All other information within this form will be collated by Council and presented in a non-identifiable manner to meet requirements of the funding body and potential program planning or funding applications.

To answer the following questions please consider your experiences over the past 30 days, as a parent of a young child.

Contact details

Gender:

(for light catering purposes)

How socially connected do/did you feel with your...

Family
Friends
Colleagues
Community

For the following questions please select the statement most appropriate when considering your experience as a parent of a young child.

I often need help from other people but can't get it.
When I need someone to help me out, I can usually find someone.
I don't have anyone that I can confide in.
I often feel very lonely.

Exercise pre-screening questionnaire

Have you ever been told that you have a heart condition?
    Have you ever had a stroke?
    Do you ever have unexplained pains in your chest at rest or during physical exercise?
    Do you consistently feel faint or suffer from spells of dizziness?
    Do you suffer from asthma and require medication?
    Do you suffer from type I or II diabetes?
    Do you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity?
    Do you suffer from any medical conditions that may be made worse by participating in physical activity?
    Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?
    Do you have a family history of heart disease? (stroke, heart attack)
    Have you been told that you have high cholesterol?
    Have you been told that you have high blood sugar?
    Have you spent time in hospital for any medical condition/illness/injury during the last 12 months?
    Do you suffer from any post natal injuries, such as bladder leakage or abdominal separation?