Health Survey

Please fill out this health survey for your own good
Gender
Birth Date

Month Day Year
Height
Height in inches
Weight
Weight in lbs
Do you smoke?

1 Pack/day 2 Packs/day +3 Packs/day No
Do you do any exercise?

1 - 3 a week 3 - 5 a week Everyday Never
How many hours do you sleep?

Less than 5 hours 5 - 6 hours 7 - 8 hours 9 - 10 hours More than 10 hours
Should be Empty:

Health Survey