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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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1
Do you smoke?
Select whether you are a smoker or not.
Yes
No
2
How would you rate your diet?
Rate your diet on a scale of 1 to 10, where 1 is poor and 10 is excellent.
3
How many hours of exercise do you do per week?
Enter the approximate number of hours of exercise you do in a week.
4
Do you consume alcohol?
Select whether you consume alcohol or not.
Yes
No
5
How many hours of sleep do you get per night?
Enter the approximate number of hours of sleep you get per night.
6
How often do you engage in stress-relieving activities?
Select how often you engage in activities to reduce stress.
Daily
Weekly
Monthly
Rarely
Never
7
Are you currently under any medication?
Select whether you are currently taking any medication.
Yes
No
8
How many glasses of water do you drink per day?
Enter the approximate number of glasses of water you drink in a day.
9
Do you have any known food allergies?
Select whether you have any known food allergies.
Yes
No
10
How often do you get regular health check-ups?
Select how often you go for regular health check-ups.
Annually
Bi-annually
Quarterly
Rarely
Never
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