Patient Lifestyle Survey
  • Name
  • Date of birth
  • Gender
  • Occupation
  • Height
  • Weight
  • Allergies
  • Known health issues

  • How active are you on a daily basis?
  • How much time would you say you are active in a given day?
  • How much time do you spend exercising each week?

  • How much time do you spend playing sports each week?

  • How much time do you spend surfing the internet or watching TV each week? 

  • List your leisure activities below. 

  • Do you smoke?

  • Please specify how often

  • Do you drink alcohol?

  • Please specify how often

  • Do you have healthcare benefits?

  • Please specify what type

  • Do you have insurance?

  • Please specify what type

That's all, folks!

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