Patient Lifestyle Survey

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0

Name
0

Date of birth
0

Gender
0

Occupation
0

Height
0

Weight
0

Allergies

0 / 5000
0

Known health issues

0 / 5000
0

How active are you on a daily basis?
Sedentary

Inactive

Slightly active

Active

Very active
0

How much time would you say you are active in a given day?
< 15 minutes

16 - 30 minutes

31- 45 minutes

45 - 60 minutes

> 60 minutes
0

How much time do you spend exercising each week?
< 1 hour

1 - 3 hours

4 - 5 hours

6 - 10 hours

> 10 hours
0

How much time do you spend playing sports each week?
< 1 hour

1 - 3 hours

4 - 5 hours

6 - 10 hours

> 10 hours
0

How much time do you spend surfing the internet or watching TV each week?
< 1 hour

1 - 3 hours

4 - 5 hours

6 - 10 hours

> 10 hours
0

List your leisure activities below.

0 / 5000
0

Do you smoke?
Yes

No
0

Please specify how often

0 / 5000
0

Do you drink alcohol?
Yes

No
0

Please specify how often

0 / 5000
0

Do you have healthcare benefits?
Yes

No
0

Please specify what type

0 / 5000
0

Do you have insurance?
Yes

No
0

Please specify what type

0 / 5000