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Health Screening Questionnaire
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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Health Screening Questionnaire
1
Do you currently have any medical conditions?
Please select yes or no.
Yes
No
2
Rate your overall health on a scale of 1 to 10.
Please rate your health from 1 (poor) to 10 (excellent).
3
Please describe your dietary habits.
Please provide a brief description of your typical daily diet.
4
Are you currently taking any medications?
Please select yes or no.
Yes
No
5
How many hours of sleep do you get on average per night?
Please enter the number of hours.
6
Do you engage in regular physical activity?
Please select yes or no.
Yes
No
7
How often do you have fruits and vegetables in your diet?
Please select the frequency.
Rarely
Occasionally
Regularly
8
Do you smoke or use tobacco products?
Please select yes or no.
Yes
No
9
How often do you consume alcohol?
Please select the frequency.
Never
Occasionally
Regularly
10
Please provide any additional health information you think is relevant.
You can add any other health information you believe is important.
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Health Screening Questionnaire
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