General Health Assessment Form
Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Please enter weight (lbs)
Please Enter Height in Feet
Please Select
3 feet
4 feet
5 feet
6 feet
and inches
Please Select
1 inch
2 inch
3 inch
4 inch
5 inch
6 inch
7 inch
8 inch
9 inch
10 inch
11 inch
Have you been gaining weight for the past 6 months?
Please Select
YES
NO
Do you wish to lose weight?
Please Select
YES
NO
MAYBE
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?
Yes
NO
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?
Yes
No
Do you currently smoke tobacco on a daily basis, less than daily, or not at all?
Daily
less than daily
Not at all
Have you smoked in the past?
Yes
No
In the past year, have you tried to stop smoking?
Yes
No
Not 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 all
Sometimes
Most of the time
Do you have problem with fall asleep, staying asleep, waking up earlyor feeling tired through out day?
None at all
Sometimes
Most of the time
During past 2 weeks, do you feel down and hopeless or depressed?
None at all
Sometimes
Most of the time
In the past 2 weeks, have you had problem with sleeping eg sleeping more than usual or sleeping lesser than usual?
Please Select
YES
NO
Do you have these medical conditions? Please check all applicable options
Diabetes
High Blood Pressure
High Cholesterol
Family history of stroke or heart disease
Autoimmune illnesses like psoriasis,lupus, Crohn disease, rheumatoid arthritis
Under stress all the time
History of stroke
History of heart attack, or congestive heart failure
History of clogged neck artery or leg artery.
Other
Submit
Should be Empty: