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Client Health Assessment
Patient Gender
*
Male
Female
Previous Ailments
High Blood Pressure
Low Blood Pressure
Diabetes
Lung Diseases
Liver Diseases
Asthma
Kidney Diseases
Nuerological Problems
Thyroid
Cancer
How often do you exercise?
Never
1-2 days a week
3-4 days a week
1 -2 days a month
Alcohol Consumption
Don't Drink
1-2 Glasses/day
3-5 Glasses/day
5+ Glasses/day
Caffeine Consumption
I avoid completely.
1-2 cups/day
3-5 cups/day
5+ cups/day
Smoke Habbits
No
0-1 Pack/day
2-3 Pack/day
3+ Pack/day
Sleeping Hours
Less than 8 hours
8-12 hours
More than 12 hours
Your Company Name
Facebook
Twitter
Linkedin
Google+
A brief intro is always great. It's Helps people to identify your company.
Address
[email protected]
800-555-0101
yoursite.com
