Disease Risk Assessment Questionnaire
Complete this questionnaire to help assess general disease risk factors. Provide only general information you are comfortable sharing.
Risk Profile
Age range
*
Under 18
18-29
30-39
40-49
50-59
60-69
70+
Sex or gender
Female
Male
Intersex
Non-binary
Prefer not to say
Family history of disease
Heart disease
Diabetes
Cancer
Stroke
High blood pressure
Autoimmune disease
None known
Other
Lifestyle and Exposure Factors
Lifestyle and Exposure Risk Assessment
*
Rows
Never/None
Low
Moderate
High
Smoking status
1
2
3
4
Alcohol use
5
6
7
8
Exercise frequency
9
10
11
12
Diet quality
13
14
15
16
Sleep quality
17
18
19
20
Stress level
21
22
23
24
Exposure to high-risk environments
25
26
27
28
Smoking status risk level
No current use
1
2
3
4
Heavy use
5
1 is No current use, 5 is Heavy use
Alcohol use risk level
None
1
2
3
4
Frequent/heavy use
5
1 is None, 5 is Frequent/heavy use
Exposure to high-risk environments
No known exposure
1
2
3
4
Frequent or ongoing exposure
5
1 is No known exposure, 5 is Frequent or ongoing exposure
Symptoms and Recent Health Indicators
Which of these general warning signs have you noticed recently?
Fever
Persistent cough
Shortness of breath
Fatigue
Unexplained weight change
Night sweats
None of these
Other
Have you experienced any recent change in your general health?
No change
Mild change
Moderate change
Significant change
Not sure
Additional context you’d like to share
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