The following three questions: 1 - 10 (1=poor / 10=excellent)

,How do you rate your current level of health,How do you rate your current level of energy or vitality,How do you rate your current stress levels,How many hours sleep do you get a night?,Do you have trouble getting to sleep?,Do you wake often, or get woken easily?,Do you have to go to the bathroom during the night?,Do you snore or have breathing problems during sleep?,Do you have known allergies?,Please list any known allergies,Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives),Please list any supplements you are currently taking,Do you have a main health complaint? Please describe.,Are there any of the following medical conditions in your family history that you are aware of? Please tick all that apply.,Additional info you might want to share,Next: Diet and lifestyle . .,Page Break,Do you exercise?,Please list the types of exercise you do regularly,Do you smoke?,How many per wk?,Do you take recreational drugs?,Please list any food allergies / intolerances that you are aware of?,How many glasses of water do you have a day?,Do you drink alcohol?,How many per week?,Page Break,Patient health history,Frequency of exercise (days per week):,Vegetarian or vegen:,Age >50 years:,Planning to have a baby in the next 3-6 months:,Pregnant or breastfeeding:,Page Break,Do you diet often?:,Are you unhappy with your weight?:,Page Break,Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:,Would you like us to E-mail you a copy of your HAQ?,Your Preferred E-mail Address,Finish"/> 'read')); $categories = $cat->read(true); if( $path['1'] === "" ){ ?>

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Health Evaluation Form

Health Evaluation Form

If you have an online health service , this forms is suitable for you. Get your patient history, lifestyle and more. Customize it to your needs Form Preview

    The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete
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