Height:
Weight:
Ethnicity:
Name:
Age:
HEALTH & LIFESTYLE
QUESTIONNAIRE
1. DO YOU TAKE ANY MEDICATION?
1a. If yes, please state.
2. DO YOU SMOKE/VAPE?
2a. If yes, how often do you smoke/vape?
3. DO YOU CONSUME ANY ALCOHOL?
3a. If yes, how often do you drink?
4. HAVE YOU EVER CONSUMED ANY ILLEGAL DRUGS/SUBSTANCES?
4a. If yes, have you consumed any in the last six months?
5. ON AVERAGE, HOW MANY HOURS DO YOU SLEEP PER NIGHT?
6. DO YOU HAVE ANY MENTAL HEALTH CONDITIONS?
If yes, please state below.
7. ON A SCALE OF 1-10 HOW WOULD YOU RATE YOUR CURRENT
STRESS LEVEL?
6a. What are the main sources of stress?
6b. Can it be managed?
Weight:
Ethnicity:
Name:
Age:
HEALTH & LIFESTYLE
QUESTIONNAIRE
1. DO YOU TAKE ANY MEDICATION?
1a. If yes, please state.
2. DO YOU SMOKE/VAPE?
2a. If yes, how often do you smoke/vape?
3. DO YOU CONSUME ANY ALCOHOL?
3a. If yes, how often do you drink?
4. HAVE YOU EVER CONSUMED ANY ILLEGAL DRUGS/SUBSTANCES?
4a. If yes, have you consumed any in the last six months?
5. ON AVERAGE, HOW MANY HOURS DO YOU SLEEP PER NIGHT?
6. DO YOU HAVE ANY MENTAL HEALTH CONDITIONS?
If yes, please state below.
7. ON A SCALE OF 1-10 HOW WOULD YOU RATE YOUR CURRENT
STRESS LEVEL?
6a. What are the main sources of stress?
6b. Can it be managed?
