Health Status Form

Most recent random blood sugar/fasting blood sugar

Below 70 mg / dL

70 – 110 mg / dL

110 - 126 mg / dL

>126 mg / dL

70 – 140 mg / dL

140 - 200 mg / dL

>200 mg / dL

I don't remember

I have never had my RBS/FBS tested

Most recent blood presure reading

I don’t remember

I have never had my Blood pressure measured

* (Avg - 130/90 mm of Hg)

Recent/Today's cholesterol level

< 200mg / dL

200 to 239 mg / dL

>240 mg / dL

I don’t remember

I have never had my cholesterol level tested

(Avg - Below 200 mg/dL)

Any family history of diabetes?

Single parent

Both parents

I have no family history

Any family history of hypertension?

Single parent

Both parents

I have no family history

Any health issue?

Diabetes

Hypertension

Hyperlipidemia/ High Cholesterol

Asthma

None of the above

Have you ever been diagnosed with any of the following disease/condition(s)?

Arthritis

Anemia

Cancer

Cardiac conditions

Chronic Kidney diasease

Chronic Liver disease

Thyroid conditions

Polycystic Ovarian Syndrome

Epilepsy/Seizure disorder

None

Taking any treatment for Diabetes?

Yes

Does Diabetes affect your routinelife at work/home?

Yes, most times

Sometimes

Taking any treatment for hypertension?

Yes

Does hypertension affect your routinelife at work/home?

Yes, most times

Sometimes

Taking regular treatment for cholesterol?

Yes

Have you modified your lifestyle for cholesterol?

Yes

Any previous asthmatic attack?
(More than two)

Yes

Do you smoke?

I do not smoke

I smoke once in a while / at parties / at social gatherings

I smoke a few times a week

I smoke everyday

Per day sticks?

1 to 10

More than 10

Per week sticks?

Less than 20

More than 20

Your best physical activity?

I exercise more than 4 times a week, 30 minutes or more

I exercise few times a week

I do only regular routine activities/ I do not exercise at all

Your best dietary practice?

Vegetarian

Non Vegetarian

Your eating habits?

I take all 3 meals regularly

I take 5 small meals at frequent intervals

I often skip my meals

Have you felt anxious, nervous or restless in previous month?

Always

Few times

Never

Have you felt depressed or sad in previous month?

Most of the time

Sometimes

Never

Have you felt overwhelmed with stress from responsibilities, situations or relationships?

Most of the time

Sometimes

Never

Your dosage for eating fried & junk food?

Almost Everyday

Sometimes

Rarely

Your alcohol drinking behavior?

I do not drink alcohol

I drink alcohol once in a while / at parties / at social gatherings

I drink alcohol 2-3 times a week

I drink 1-2 pegs of alcohol everyday

I drink 3 or more pegs of alcohol everyday

I used to drink alcohol but do not drink anymore

Your Health

What is Your Age

Gender

My Height is

My Weight is

Most recent random blood sugar/fasting blood sugar

Most recent blood presure reading

Recent/Today's cholesterol level

Any family history of diabetes?

Any family history of hypertension?

Any health issue?

Have you ever been diagnosed with any of the following disease/condition(s)?

Taking any treatment for Diabetes?

Does Diabetes affect your routinelife at work/home?

Taking any treatment for hypertension?

Does hypertension affect your routinelife at work/home?

Taking regular treatment for cholesterol?

Have you modified your lifestyle for cholesterol?

Any previous asthmatic attack?
(More than two)

Do you smoke?

Per day sticks?

Per week sticks?

Your best physical activity?

Your best dietary practice?

Your eating habits?

Have you felt anxious, nervous or restless in previous month?

Have you felt depressed or sad in previous month?

Have you felt overwhelmed with stress from responsibilities, situations or relationships?

Your dosage for eating fried & junk food?

Your alcohol drinking behavior?

SUCCESSFUL

Wait For Result ...

Your Health

What is Your Age

Gender

My Height is

My Weight is

Most recent random blood sugar/fasting blood sugar

Most recent blood presure reading

Recent/Today's cholesterol level

Any family history of diabetes?

Any family history of hypertension?

Any health issue?

Have you ever been diagnosed with any of the following disease/condition(s)?

Taking any treatment for Diabetes?

Does Diabetes affect your routinelife at work/home?

Taking any treatment for hypertension?

Does hypertension affect your routinelife at work/home?

Taking regular treatment for cholesterol?

Have you modified your lifestyle for cholesterol?

Any previous asthmatic attack?(More than two)

Do you smoke?

Per day sticks?

Per week sticks?

Your best physical activity?

Your best dietary practice?

Your eating habits?

Have you felt anxious, nervous or restless in previous month?

Have you felt depressed or sad in previous month?

Have you felt overwhelmed with stress from responsibilities, situations or relationships?

Your dosage for eating fried & junk food?

Your alcohol drinking behavior?

SUCCESSFUL

Wait For Result ...

Error !!

Any previous asthmatic attack?
(More than two)