General Health Assessment Form

General Health Assessment Form
Name

First NameLast Name
Birthday

MonthDayYear
Date
Please enter weight (lbs)
Please Enter Height in Feet
and inches
Have you been gaining weight for the past 6 months?
Do you wish to lose weight?
In the past year, have you used any recreational drugs?

Opioid (Opium, Heroin)Stimulants (Cocaine, Amphetamine)Hallucinogens (LSD, Mescaline)Carbinoids (Marijuana)None of the above
Do you somtimes drink beer, wine, or other alcoholic beverage?

YesNO
In the past one month, how many times you have 4 or more alcoholic drinks in a day?
Have you ever felt you should cut down on your drinking?

YesNo
Do you currently smoke tobacco on a daily basis, less than daily, or not at all?

Dailyless than dailyNot at all
Have you smoked in the past?

YesNo
In the past year, have you tried to stop smoking?

YesNoNot applicable. I do not smoke.
During past 2 weeks, do you lose interest or pleasure in doing things you usually like to do?

None at allSometimesMost of the time
Do you have problem with fall asleep, staying asleep, waking up earlyor feeling tired through out day?

None at allSometimesMost of the time
During past 2 weeks, do you feel down and hopeless or depressed?

None at allSometimesMost of the time
In the past 2 weeks, have you had problem with sleeping eg sleeping more than usual or sleeping lesser than usual?
Do you have these medical conditions? Please check all applicable options

DiabetesHigh Blood PressureHigh CholesterolFamily history of stroke or heart diseaseAutoimmune illnesses like psoriasis,lupus, Crohn disease, rheumatoid arthritisUnder stress all the timeHistory of strokeHistory of heart attack, or congestive heart failureHistory of clogged neck artery or leg artery.Other
Should be Empty: