Health Questionnaire

Personal Information

Let us start with some basic information about you.

Age

Gender

MaleFemale

Please provide your physical information.

Height (cm)

Weight (kg)

Please answer the following questions about your health.

Do you smoke?

Yes No

Have you or any family member ever been diagnosed with heart disease?

Yes No

Have you or any family member ever been diagnosed with diabetes?

Yes No

Have you or any family member ever been diagnosed with thyroid disease?

Yes No

Review your information.

Age:-

Gender:-

Height (cm):-

Weight (kg):-

Do you smoke?:-

Have you or any family member ever been diagnosed with heart disease?:-

Have you or any family member ever been diagnosed with diabetes?:-

Have you or any family member ever been diagnosed with thyroid disease?:-