Your Details

  • Your Details
  • Health History
  • Family History
  • My Habbits
  • My Diet
  • Medication

Your Gender?

Male

Female

Your Age?

Your Height?

Your Weight (in Kgs)?

Kg
Have you ever been diagnosed with : (Choose all that apply)

High blood pressure (hypertension)

High blood cholesterol

Diabetes or a problem with blood sugar

Heart Disease/Had a Heart Attack

Stroke

Cancer - Any type other than basal or squamous cell skin cancer

Liver Diesease

Chronic kidney diesease/Udergoing Dialysis

Immune Deficiency

None

Has anyone in your immediate family (mother, father, sister, brother) had? : (Choose all that apply)

Heart Disease

Stroke

Diabetes

None

Do you have a family history (on your mother's side or your father's side) of any of the following? : (Choose all that apply)

Breast and / or Ovarian Cancer

Cervical Cancer

Diabetes or a problem with blood sugar

Colorectal Cancer

Lung Cancer

Uterine Cancer

Prostrate Cancer

Stomach Cancer

None

Do you have any brothers or sisters diagnosed with Cancer

Yes

No

Your Smoking History
Do you smoke cigarettes?

Yes

No - I Never Smoked

I have Quit Smoking

How old were you when you started smoking?

How many cigarettes

How old were you when you started smoking?

How many cigarettes

At what age did you quit smoking?

Your Drinking History
Do you drink alcohol?

Yes

No - I Never Drank alcohol

No - I have Quit Drinking Alcohol

How old were you when you started drinking?

On average how many servings of alcohol did you have per day? One serving is equal to one peg of hard liquor / one can of beer / one glass of wine

How old were you when you started drinking?

On average how many servings of alcohol did you have per day? One serving is equal to one peg of hard liquor / one can of beer / one glass of wine

At what age did you quit Drinking?

Your Physical Activity
Do you walk (exercise or do other moderate physical activity) for at least 30 minutes on most days of the week, or at least do moderate physical activity for 3 hours per week?

Yes

No

How many non-work hours per day do you spend watching television shows, playing video games, or using a computer/tablet?

Less than 1 hour

1 hour

2 hour

3 hour

4 hour

More than 5 hours

Do you eat three or more servings of processed meat in a week? (Processed meats include foods like: ham, hot dogs, bacon, and sausage)

Yes

No

Do you eat butter, lard / fat, red meat (Beef, Mutton, Lamb, Pork), cheese, or whole milk 2 or more times per day?

Yes

No

Do you eat fish two or more times in a week?

Yes

No

Do you eat oil-based salad dressing or use liquid vegetable oil for cooking on most days?

Yes

No

Do you eat at least 3 servings of nuts per week?

Yes

No

Do you take a multivitamins for more than four days in a week?

Yes

No

Have you been taking multivitamins regularly for 12 years or more?

Yes

No

Do you take an aspirin every day?

Yes

No

Have you taken aspirin 2 or more times per week for 6 or more years?

Yes

No