Health Check Form – Step 3

Well done , and here are the most important questions:

STEP 3:

1

2

3

4

5

Do you drink coffee, black or green tea regularly?

Yes No

Do you smoke or vape?

Yes No

Are you taking any prescription medication now or in the last four weeks?

Yes No

-- What medication, for how long, and why?

-- Upload you medication image

Do you suffer from headaches or migraines?

Yes No

Do you have any back pain or injury now or in the past?

Yes No

Do you suffer from low or high blood pressure?

Yes No

-- What is your blood pressure reading and when was it measured?

Are you pregnant or breastfeeding?

Yes No

-- How many weeks pregnant are you or how long have you been breastfeeding?

Have you had any surgery in the last six months?

Yes No

-- what kind of surgery, when, and how did it go?

Do you have any digestive issues or diseases now or in the past?

Yes No

-- What is the diagnosis, treatment, and current status of your condition?

Are you prone to vomiting, diarrhea, or constipation?

Yes No

Do you have any heart, liver, or kidney disease now or in the past?

Yes No

-- What is the diagnosis, treatment, and current status of your condition?

Are you being treated for type 1 or type 2 diabetes mellitus?

Yes No

-- What is your blood sugar level and when was it measured?

Do you have or have you ever had an eating disorder?

Yes No

Do you have or have you had a food allergy/intolerance?

Yes No

-- What food are you allergic or intolerant to, and what are the symptoms?

Do you have any thyroid disorder now or in the past?

Yes No

-- What type of thyroid disorder, how is it treated, and what is your current status?

Have you lost more than 5% of your body weight in the last six months without trying?

Yes No

-- How much weight did you lose and why do you think it happened?

Do you have any mental health condition now or in the past?

Yes No

-- What type of mental health condition, how is it treated, and what is your current status?

Do you have any other health concerns we have not asked you about in this form? If yes, please explain.