ENERVARA Condition Care Assessment
Assess how well you’re managing your condition and get personalized tips for safe and healthier living
Full Name
*
Mr.
Mrs.
Prefix
First Name
Last Name
What is your age?
*
Height
*
Weight
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email
*
Check the conditions that apply to you or any member of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
PCOS
Other
When were you first diagnosed?
*
Less than 1 year
1-5 years
More than 5 years
Check the symptoms that you' re currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
None
Other
Are you under doctor's care currently?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you go for regular follow ups?
*
Never
Only when symptoms worsen
Once a year
Every 3-6 months
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do your monitor your condition at home? (For diabetes how often you monitor your blood glucose levels)?
Daily
Weekly
Monthly
Never
Do your monitor your condition at home? (For hypertension how often you monitor your blood pressure levels)?
Daily
Weekly
Monthly
Never
For other conditions, do you use any health monitoring devices?
Yes
No
How to often you follow doctor recommended diet?
*
Always
Sometimes
Rarely
Never
How often do you exercise or do physical activity?
*
Never
1-2 times a week
2-4 times a week
Daily
How often do you miss your prescribed medication?
*
Never
Rarely
Sometimes
Often
How well do you feel your condition is controlled?
*
Very well
Moderately well
Poorly
Not sure
How often does your condition affects daily routine?
*
Never
Rarely
Sometimes
Often
Always
Do you experience stress or anxiety related to your condition?
*
Never
Rarely
Sometimes
Often
Always
Submit
Should be Empty: