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General Health Questionnaire
1. Full Name
2. Gender
Male
Female
Other
3. Contact Information
ISD
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Phone No.
Email
4. What is your Health Goal ?
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Any Other Notes
5. Date of Birth
6. Height
Feet
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Inch
Please Select
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7. Weight (in Kg)
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Kg/m
2
8. Waist Circumference (in inches; please measure right above belly button with the tape parallel to the ground and a relaxed abdomen):
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Kg/m
2
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
