How old are you?

What is your gender?

What is your ethnic background?

How would you rate your physical health?


How would you rate your overall mental/emotional health?


How would you rate your stress levels?


Do you have any chronic health conditions?

Please specify your chronic health conditions

Do you have any hereditary conditions/diseases?

Please specify your hereditary conditions/diseases

Do you smoke or use tobacco products?

How often do you consume alcohol?


How would you rate your level of physical activity?


How many hours of sleep do you typically get per night?


Have you experienced any significant weight changes in the past year?

Do you have any allergies?

Healthcare Services

How often do you visit your primary care physician?

Have you ever been admitted to the hospital?

Please specify your reason for hospitalization

Do you have health insurance?

If you do not have health insurance, why not?

Please share any additional comments or concerns regarding your health