Lifestyle
Please answer the following questions about your lifestyle.
Please enter your email address if you would like to be sent a copy of your completed questionnaire.
example@example.com
Do you smoke?
*
Yes
No
How much alcohol do you drink per week? (1 unit is equal to approximately 1 small glass of wine or 1/2 pint lager/beer/cider)
*
Do you exercise regularly?
*
Yes
No
If yes, how many times per week?
*
Please provide any additional information or concerns you would like to share with your healthcare team.
Submit
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