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Health Assessment Form
Fill in the details below so that our physician can analyze your health in general before consultation
In general how would you rate your health?
Excellent
Good
Fair
Poor
In past 7 days how often did you exercised?
Every day
3-6 days
1-2 days
0 days
In last 7 days how often did you eat more than 3 servings of fruits or vegetables in a day?
Everyday
3-6 days
1-2 days
0 days
In the last 7 days, how often did you have (5 or more for men, 4 or more for women) alcoholic drinks at one time
Never
Once a week
2-3 times
More than 3 times
In the last 30 days, how often have you felt tense, anxious or depressed?
Almost every day
Sometimes
Rarely
Never
Do you use drugs or medications (other than exactly as prescribed for you) which affect your mood or help you to relax?
Almost every day
Sometimes
Rarely
Never
How long has it been since your last checkup?
Within the last year
Between 1-3 years
More than 3 years
Have you been previously diagnosed with any of the following?
Heart Disease
High Blood Pressure
High Cholestrol
Diabetes
Stroke
Cancer
Other
Your family has/had this genetic disease
Heart Disease
High Blood Pressure
High Cholestrol
Diabetes
Stroke
Cancer
Other
Gender
Male
Female
Your Company Name
Facebook
Twitter
Linkedin
Google+
A brief intro is always great. It's Helps people to identify your company.
Address
[email protected]
800-555-0101
yoursite.com
