top of page
Services
Program
Success Stories
Employers
Resource Center
About Us
Use tab to navigate through the menu items.
User
Log Out
Log in
Krishna Kumar
8630586970
8630586970
Profile
My Orders
H+ Points
Surveys
Settings
Community
General
Diabetes
CVD
Mental Health
Name
Date
Time
H+ Points
Name
22' Jan 2022
22' Jan 2022
2 H+ Points
Heading 6
Name
22' Jan 2022
22' Jan 2022
Heading 6
Name
22' Jan 2022
22' Jan 2022
Submission Date : 22/08/2022
1. Full Name
2. Gender
Male
Female
Other
3. Contact Information
ISD
arrow&v
Phone No.
Email
4. What is your Health Goal ?
arrow&v
If other (Please Specify)
5. Date of Birth
6. Height
Feet
arrow&v
Inch
arrow&v
7. Weight (in Kg)
8. Waist Circumference ( in Inches ) :
9. Do you have any medical concerns? Please select all that apply.
Type 2 Diabetes / Prediabetes
Type 1 Diabetes
Hypertension
Heart Disorders (Coronary Artery Disease (CAD)/ Heart Arrhythmias/ Heart Failure/ Heart Valve Disease/ Pericardial Disease/ Cardiomyopathy/ Congenital Heart Disease)
Obesity or Overweight
High Waist Circumference or Belly Fat
Endometriosis
PCOS / PCOD
Thyroid Disorders (Hypothyroidism/ Hyperthyroidism/ Hashimoto's Disease/ Grave's Disease/ Goiter)
High cholesterol or high lipids or high triglycerides (hypercholesterolemia/ dyslipidemia/ hypertriglyceridemia)
Kidney disorders (high serum creatinine/ urine microalbumin)
Fatty Liver
Gastrointestinal Disorder (Inflammatory bowel disease/ Irritable Bowl Syndrome/ Celiac Disease/ GERD/Acid Reflux/ SIBO)
Mental Health Disorder (Clinical Depression/ Anxiety Disorder/ Schizophrenia/ Bipolar Disorder/ Dementia/ OCD/ PTSD)
other
None
If other (Please Specify)
10. Do you have family history of any of these conditions? Please select all that apply.
Type 2 Diabetes / Prediabetes
Type 1 Diabetes
Hypertension
Heart Disorders (Coronary Artery Disease (CAD)/ Heart Arrhythmias/ Heart Failure/ Heart Valve Disease/ Pericardial Disease/ Cardiomyopathy/ Congenital Heart Disease)
Obesity or Overweight
High Waist Circumference or Belly Fat
Endometriosis
PCOS / PCOD
Thyroid Disorders (Hypothyroidism/ Hyperthyroidism/ Hashimoto's Disease/ Grave's Disease/ Goiter)
High cholesterol or high lipids or high triglycerides (hypercholesterolemia/ dyslipidemia/ hypertriglyceridemia)
Kidney disorders (high serum creatinine/ urine microalbumin)
Fatty Liver
Gastrointestinal Disorder (Inflammatory bowel disease/ Irritable Bowl Syndrome/ Celiac Disease/ GERD/Acid Reflux/ SIBO)
Mental Health Disorder (Clinical Depression/ Anxiety Disorder/ Schizophrenia/ Bipolar Disorder/ Dementia/ OCD/ PTSD)
other
None
If other (Please Specify)
11. Do you experience any of these symptoms ?
Extreme Thirst
Frequent Urination
Vision problems
Dry & itchy skin
Low energy / Tiredness
Hypoglycemia
Confusion / Brain Fog
Anxiety
Mood Swings
Numbness / Tingling in Hands or Feet
Lightheadedness / Fainting
Shortness of Breath
Nosebleeds
Heart Palpitations
Hunger Pangs
Irregular Menstrual Cycle
Acne
Hirsutism
Thinning of Hair
Stress
Constipation
Acidity
Bloating