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Health check questionnaire

(Free with 1st purchase)

Please complete the questionnaire below. Please note that your contact information will not be shared with any parties, and is only for our use in making contact with you. 
Name Age Gender Phone E-mail Medical History
Please answer the following (tick if yes, leave blank if no)
Do you have any chronic medical conditions
Have you undergone any surgeries in the past?
Are you currently taking any medications or supplements?
If you answered yes to any of these please specify info below. Do you smoke? If yes, how many cigarettes per day? Do you consume alcohol? If yes, how frequently and in what quantities? Do you exercise regularily? If yes, what type and how often? Are you experiencing any pain or discomfort? If yes, please describe the symptoms: Have you noticed any significant changes in your weight lately? If yes, please provide details: Do you have any allergies? If yes, please specify the allergens: Does your immediate family (parents / siblings) have a history of any chronic illnesses? If yes, please specify: How would you rate your overall mental and emotional well-being on a scale of 1-10 (with 1 being poor and 10 being excellent)? Have you experienced any significant stress or emotional difficulties recently? If yes please provide details: How many hours of sleep do you typically get per night? Do you have any difficulty falling asleep or staying asleep? If yes, please describe: How would you explain your daily diet? (eg. balanced, high in processed foods, vegetarian/vegan, etc.) Do you have any specific dietary restrictions or preferences? I agree to the Terms & Conditions and Privacy Policy Submit
Please note that this questionnaire is for informational purposes only and does not substitute professional medical advice. If you have any concerns about your health, it is recommended to consult with a healthcare professional or primary care physician.