Health Declaration Form
This form is a substitute for an official medical health certificate of fitness to work. It will take about 5 minutes to complete. Thank you.
Full Name
*
First Name
Last Name
Gender born with
*
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
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
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
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 or have sought health care in the past 6 months?
*
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 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.
*
Have you experienced any of the medical conditions below? 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
None
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?
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
Have you received a Covid-19 vaccination?
*
Please Select
No
Yes
Have you been diagnosed with Covid-19 or wasn't diagnosed but felt many of the symptoms?
*
Please Select
No
Yes
Are you planning to have a baby in the next 3-6 months?
*
Please Select
No
Yes
Are you pregnant?
*
Please Select
No
Yes
Around how many months pregnant are you?
No
Yes
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
*
Back
Next
Signature
Finish
Should be Empty: