Lifestyle Questionnaire | Wellness Company

First Name

Email Address

Last Name

What is your current occupation

On average how many cigarettes do you smoke a day?

On average how many hours do you sleep per night?

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? If yes, please explain.

Have you ever had any surgeries? If yes, please explain.

Has a medical doctor ever diagnosed you with a chronic disese, such as coronary heart disease, coronary artery disese, hypertension (high blood pressure), high cholesterol, or diabetes? If yes, please explain.

Are you currently taking any medication? If yes, please explain.

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