Health Challenges Survey

Health Challenges Survey

Here's a great way to create a medical form to be used as a survey for a Healthcare Assessment. Form Preview
JotForm
  • Health Challenge Survey

  •  -
  •   You Friend Family
    Asthma / Bronchitis
    Allergies / Hay Fever
    Allergic Reactions
    Migraines
    Diabetes
    High Blood Pressure
    Psoriasis
    Damaged Artery Lining
    Joint Flexibility
    Arthritis Inflammation / Pain
  •   You Friend Family
    Ulcers
    Gout
    High Insulin Needs
    Diabetic Retinopathy
    Macular Degeneration
    Cataracts / Glaucoma
    Vascular Disease
    Weak Arteries / Veins
    Good Cellular Collagen / Elasticity
    Poor Lower Leg Blood Volume
  •   You Friend Family
    Respiratory Inflammation
    Frequent Infections / Flu / Colds
    High Histamine Levels / Sinus Problems
    Low Energy / Fatigue
    Chronic Fatigue
    Lupus
    Immune Deficiency
    Hepatits C
    High Cholesterol
    Poor Capillaries
    Crohn's Disease
    Constipation
  •   You Friend Family
    Fat Formation / Cellulite
    Varicose Veins
    Phlebitis
    Rough Skin
    Bruising / Cracking Skin
    Eczema
    Sports Injuries
    Muscle Cramps
    Parkinson's
    Vertigo (Dizziness)
    Headache Pain
    Poor Circulation
  •   You Friend Family
    Spasms
    Alzheimer's
    Environmental Concerns
    Wrinkling of the Skin
    Pollution
    Drugs
    Alcohol
    Smoke
    All Free Radical Damage
  •   You Friend Family
    Carpal Tunnel Pain
    ALS
    ADD / ADHD
    Fibromyalgia
    MS
    Hemorrhoids / Prostate Problems
    Menopause / PMS / Cramps
    Aging Concerns
    Cancer Risk

  •   Name Relationship Cell Phone Email Address
    Referral 01
    Referral 02
    Referral 03
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