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Health survey (copy)

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?