Date

Name

Age

Gender

• Male

• Female

Email

Phone Number

1. Do you have any existing medical conditions?

If yes, please specify:

2. Are you currently taking any medications?

If yes, please list:

3. Have you had any surgeries or hospitalizations in the past?

If yes, please describe:

4. How often do you exercise?

• Daily

• Several times a week

• Once a week

• Rarely

• Never

5. How would you describe your diet?

• Healthy and balanced

• Mostly healthy

• Average

• Unhealthy

6. How many hours of sleep do you typically get each night?

• Less than 5

• 5-6

• 7-8

• More than 8

7. Do you have any specific health concerns you would like to address?

If yes, please specify:

8. Is there anything else you would like us to know about your health?

If yes, please specify:

9. On a scale of 1 to 10, how would you rate your overall stress level?

10. Do you have access to regular healthcare services?

Please check the box below to proceed