Health Assessment Form
Health Assessment Form
Age:
Gender:
Select gender
Male
Female
On a scale from 1 (lowest) to 9 (highest), update the following:
Air Pollution:
Alcohol use:
Dust Allergy:
Occupational Hazards:
Genetic Risk:
Chronic Lung Disease:
Balanced Diet:
Obesity:
Smoking:
Passive Smoker:
Chest Pain:
Coughing of Blood:
Fatigue:
Weight Loss:
Shortness of Breath:
Wheezing:
Swallowing Difficulty:
Clubbing of Finger Nails:
Frequent Cold:
Dry Cough:
Snoring: