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Dr Sztembis cardio visit

Please answer following questions before the visit.

Your answers will help me get prepared to meet you.

Thank you for your participation!!

Zabezpieczony
Survio
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Dr Sztembis cardio visit
1

Please enter your ID code sent via sms/WhatsApp message/e-mail.

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Dr Sztembis cardio visit
2

How old are you?

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Dr Sztembis cardio visit
3

Have you ever been an active smoker?

Wybierz jedną odpowiedź
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Dr Sztembis cardio visit
4

If you used to smoke but have quit, please let me know how long you smoked and how many cigarettes you typically smoked per day. (If you have never smoked, you can skip this question.)

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Dr Sztembis cardio visit
5

Have anyone in your family experienced heart disease or other chronic diseases like diabetes, rheumatoid arthritis, cancer? If yes, then at what age? Please give as many details as possible.

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Dr Sztembis cardio visit
6

Do you snore?

Wybierz jedną odpowiedź
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Dr Sztembis cardio visit
7

What is an average duration of your sleep?

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Dr Sztembis cardio visit
8

Do you have any history of allergies or food intolerance?

Wybierz jedną odpowiedź
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Dr Sztembis cardio visit
9

Please describe your allergies or food intolerance.

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Dr Sztembis cardio visit
10

Do you take any food supplements? Please write YES (*) or NO.

(*) if YES - please write down all supplements you take
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Dr Sztembis cardio visit
11

If you are currently taking any medications, please list their names, dosages, and how long you have been taking them.

If you have never taken any medications, please skip this slide.
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Dr Sztembis cardio visit
12

Please let me know what kind of surgical procedures you have underwent?

If none, skip that slide.
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Dr Sztembis cardio visit
13

How would you rate your overall quality of life?

1 star - the worst I can imagine; 10 stars - the best I can imagine
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Dr Sztembis cardio visit
14

How would you rate your all quality of social relations?

1 star - the worst I can imagine; 10 stars - the best I can imagine
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Dr Sztembis cardio visit
15

How would you rate your overall quality of work?

1 star - the worst I can imagine; 10 stars - the best I can imagine
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Dr Sztembis cardio visit
16

How would you rate your overall quality of sleep?

1 star - the worst I can imagine; 10 stars - the best I can imagine
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Dr Sztembis cardio visit
17

How would you rate your overall work satisfaction?

1 star - the worst I can imagine; 10 stars - the best I can imagine
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Dr Sztembis cardio visit
18

How would you rate your overall satisfaction with the way you take care of your health?

1 star - the worst I can imagine; 10 stars - the best I can imagine