Health Check-up
Gather information regarding a patient's health
Email *
What is your name?
What is your height? *
What is your weight? *
How would you rate your health?
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Do you smoke?
Have you used any non-medical drugs recently? *
Do you consume alcohol? *
How often do you exercise?
Clear selection
How many hours do you sleep daily?
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What time do you go to sleep?
Time
:
When do you wake-up in the morning?
Time
:
Are you allergic to any medication? if yes, please state which medication. *
Do you follow any of these Diets?
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Do you have any Food Allergies? If yes, please state which food. *
What are your health concerns?
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