Health Assessment Questionnaire
Health Assessment Questionnaire
Please fill out this questionnaire to help us better understand your overall health.
Personal Information
Name
Age
Gender
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Male
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Female
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Phone number
Questionnaire
Do you have any chronic conditions or allergies?
If yes, please specify
Do you currently take any prescription medications?
If yes, please list
Do you smoke?
How often do you consume alcohol?
How often do you exercise?
How would you describe your diet?
How would you rate your stress level?
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Low
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Medium
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High
How would you rate your overall health?
Is there anything else you would like to share?
Please check the box below to proceed
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Thank you for completing this assessment!
This information will assist us in tailoring your healthcare needs.
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