Health pre-assessment form

Required fields0% completed

Initial assessment tailored to you The information you share helps us organize a suitable service and initial conversation.

Basic information

Enter your age, height and weight.

Age *

years

Height *

Weight *

List any previous surgeries and their dates.

Previous surgeries and dates *

A details field will appear when you select “Yes”.

Do you have any chronic medical condition? *

Yes No

Do you have an infectious disease? *

Yes No

Do you have any medication, food or other allergies? *

Yes No

List any medication you take regularly.

Do you take any medication regularly? *

Yes No

Describe your use and how often.

Do you smoke? *

Yes No

Do you drink alcohol? *

Yes No

WhatsApp will open with your answers prepared. You can review the message before sending it.