Chronic Illness Lifestyle Support Evaluation Form
Help us understand your lifestyle, challenges, and support needs related to your chronic condition.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
What is your primary chronic illness diagnosis?
*
How would you describe your current lifestyle habits? (Select all that apply)
Balanced diet
Regular physical activity
Adequate sleep
Stress management practices
Medication adherence
Other
What are your main challenges in managing your condition? (Select all that apply)
Access to healthy food
Motivation for physical activity
Managing stress
Medication side effects
Lack of social support
Other
What kind of support or resources would be most helpful for you?
Please share any additional comments or information that may help us support you better.
Submit Evaluation
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