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Health survey
Personal Information
first name
*
last name
*
email
*
Phone no.
gender
Male
Female
Age
Address
Postal / Zip Code
City
State
Country
Medical Informatoin
Do you have any of the following?
High blood pressure
Diabetes - Type 1
Diabetes - Type 2
Other
Are you taking any medications for
Diabetes
Thyroid
High blood pressure
Lithium
High cholesterol
Are you nursing?
Yes
No
Do you have any food allergies?
Yes
No
Hydration
In a day, how much water do you drink usually?
In a day, how much coffee do you drink usually?
In a week, how much alcohol do you consume usually?
How many times per week do you exercise?
When do you eat your first meal?
When do you eat your last meal?
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