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Health Guidance Questionnaire

Health Guidance Questionnaire

Not sure where to begin? This questionnaire helps us understand your overall health, lifestyle, and goals so we can guide you to the most suitable services, plans, and support.

What service are you looking for today?*

Personalised vitamins and supplements

Gut health testing

DNA testing to personalise your nutrition and health

Weight loss programs

Blood tests to track biomarkers and measure progress

Other (please specify):

Full Name*

Age*

Phone*

Email*

Gender assigned at birth*

Height*

Weight*

Do you have a family history of any of the following?*

Heart disease

Stroke

Diabetes

High blood pressure

Cancer

Autoimmune diseases

Mental health

Osteoporosis or arthritis

Obesity

Asthma or allergies

Thyroid disorders

Kidney disease

Other (please specify):

Do you see a doctor or specialist for any ongoing health conditions? If so, please list the conditions and the type of doctor/specialist.*

Do you have any ongoing health conditions? Autoimmune diseases, thyroid issues, digestive disorders (e.g., IBS, Crohn’s), cardiovascular diseases, mental health conditions, asthma, eczema, menstruation irregularities, other female health issues, etc*

If you currently take any medications or supplements, please list them here, (name, dose, regularity) or say "None" if you don't take any.*

Please list any antibiotics you've taken in the last 6 months and specify why they were prescribed*

Do you experience any of the following?*

Joint pain or stiffness

Weight gain

Weight loss

Frequent infections

Dry eyes

Persistent fatigue

Dry skin

Hair loss

Inflamed gums

Pre-diabetes

Low mood

Bloating

Loose stools

Constipation

Menstrual issues

Regular headaches

Other (please state)

Choose your current health/wellness goals – choose up to 3:*

Boosting energy levels

Boost mental performance

Reduce anxiety

Improve stress tolerance

Improve skin, hair & nails

Reduce inflammation

Boost immunity

Improve sleep

Optimise muscle recovery

Boost digestive health

Reset metabolism

Improving general health

DNA testing to understand genetic profile

Other (please specify):

Please list your top 3 health priorities*

Do you follow a specific diet? (Vegan, Keto, Low carb etc)*

How many times do you eat fish per week? Please specify which fish*

How much dairy do you consume per day? Please specify the types of dairy*

How much protein do you eat per day? Please specify the types of protein*

If applicable, please list any allergies or intolerances you have*

On average, how many fruits do you eat per day?*

On average, how many vegetables do you eat per day? *

How much tea and coffee do you drink per day? Please specify*

On average, how many and how much alcohol do you drink per week? *

How often do you exercise per week?*

Do you smoke or vape? If yes, please specify which and how often per day*

How would you describe your activity level? *

Sedentary (less than 5,000 steps per day)

Lightly active (5,000 – 7,500 steps per day)

Moderately active (7,500 – 10,000 steps per day)

Very active (more than 10,000 steps per day)

Your fitness routine includes (choose all that apply):*

Resistance training (weights)

High-intensity (circuit/group fitness classes)

Endurance (running/cycling)

Team sports (football, netball, etc.)

Low impact (yoga, Pilates, etc.)

Walking

None

Other (please state)

What do you care most about when exercising? (choose as many as you like):*

Performance

Breaking a sweat

Muscle toning

Cardiovascular fitness

Muscle building

General health

Mental health

Other (please specify):

On average, how many hours of sleep do you get per night?*

How would you rate the quality of your sleep? (Light, Restful or Interrupted)*

On a scale of 1-10, how would you rate your current stress levels? (1 = No stress at all, 10 = Extremely stressed, feeling overwhelmed) Please list the reason/s for stress*

When it comes to living a healthy lifestyle, you are:*

Extremely dedicated

Mildly motivated - it depends on the day

Ready to get started

Please confirm that you are happy to receive information about your recommended supplements, tests, or a suggestion for a comprehensive appointment via email*

Yes

No

Please confirm that you are happy for Oranga to contact you with product launches, exciting updates, and company news*

Yes

No

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