HEALTH EVALUATION FORM
The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
E-mail
Phone Number
-
Area Code
Phone Number
Back
Begin
GENERAL INFORMATION
Name of Doctor or other health professionals you are currently seeing
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
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1991
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1988
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1986
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1981
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height if known
Weight if known
What are the main reasons you are seeking health care?
*
Weight loss
Detox
Disease Prevention
Pre-conception & Pregnancy Care
Digestive Support
Cardiovascular Protection
Stress Management
Dietary Advice
Energy
Immune System
Sports Enhancement
Pain Management
Other
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health
*
How do you rate your current level of energy or vitality
*
How do you rate your current stress levels
*
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
*
Please Select
No
Yes
Do you wake often, or get woken easily?
*
Please Select
Yes
No
Do you have to go to the bathroom during the night?
*
Please Select
Yes
No
Do you snore or have breathing problems during sleep?
*
Please Select
Yes
No
Not sure
Do you have known allergies?
*
Please Select
Yes
No
Please list any known allergies
*
Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives)
Please list any supplements you are currently taking
Do you have a main health complaint? Please describe.
Are there any of the following medical conditions in your family history that you are aware of? Please tick all that apply.
Arthritis
Asthma
Autoimmune Disorders (e.g. lupus, rheumatoid arthritis)
Bowel Disorders
Cancer
Dementia / Alzeihmers
Depression
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Low Blood Pressure
Mental Illness
Muscular Dystrophy
Obesity
Osteoporosis
Osteoporosis
Skin Disorders
Strokes
Thyroid Over Active
Thyroid Under Active
Other
Additional info you might want to share
Next: Diet and lifestyle . .
Back
Next
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Please list the types of exercise you do regularly
Do you smoke?
*
Please Select
Yes
No
How many per wk?
Do you take recreational drugs?
Please Select
Yes
No
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?
*
Do you drink alcohol?
Yes
No
How many per week?
*
Back
Next
Patient health history
Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Vegetarian or vegen:
*
Please Select
No
Yes
Age >50 years:
*
Please Select
No
Yes
Planning to have a baby in the next 3-6 months:
*
Please Select
No
Yes
Pregnant or breastfeeding:
*
Please Select
No
Yes
Back
Next
Do you diet often?:
*
Please Select
No
Yes
Are you unhappy with your weight?:
*
Please Select
No
Yes
Back
Next
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
*
Would you like us to E-mail you a copy of your HAQ?
*
Please Select
Yes
No
Your Preferred E-mail Address
*
Finish
Should be Empty: