On a scale of 1 to 10, how healthy do you consider yourself?
Do you currently suffer from any chronic diseases?
Do you have any hereditary conditions/diseases?
High blood pressure
Are you habituated to drugs and alcohol?
Yes to both
Only to drugs
Only to alcohol
I am not habituated to either
How often do you get a health checkup?
Once in 3 months
Once in 6 months
Once a year
Only when needed
Never get it done
How would you evaluate your overall health? Would you say you are:
In good physical health (No illness or disabilities).
Mildy physically impaired. (Minor illness or disabilities)
Moderately physically impaired. (Requires substantial treatment)
Severely physically impaired. (Requires extensive treatment)
Totally physically impaired. (Confined to bed)
In your opinion, at what capacity can you perform everyday activities?
Severely impaired capacity
Completely impaired capacity
In the past 24 hours, what different kinds of medications have you taken?
How many medications have been prescribed by your physician that you have taken in the last 24 hours?
More than 5