HEALTH SELF-ASSESSMENT QUESTIONNAIRE PREVENTIVE TREATMENT

Full Name

Birth Date

Phone

Email address

Please fill out this questionnaire. Your doctor will analyze this information and provide you with a conclusion after comparing it with the results of the tests.

Life Story

Regularly taken medications

Consumption of alcohol

Yes

Taking antibiotics in the last 3 months

If yes, how many grams per week?

Adverse occupational/environmental factors

Use of painkillers, antidepressants, or hypnotics in the past 3 months

Yes

Disability category

Yes

Allergy

Yes

Suffered illnesses/surgeries

Vaccination status

OTHER INFORMATION / Lifestyle and habits /

Are you physically active most of the day?

Yes

Indicate your daily physical activity level

sedentary (≤ 1500 steps/day)

average (1,500-8,000 steps/day, no regular exercises)

walking (≥ 8,000 steps/day, regular) exercises, swimming, cycling)

CURRENT HEALTH ASSESSMENT /in case of relevant complaints, please specify/