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 a week?
  • How much time do you spend playing sports a week?
  • How much time do you spend surfing the internet or watching TV every week?
  • What leisure activities do you participate in? Please list them 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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