Wellness Health Questionnaire

How did you find out about the Prama Wellness Center?
  
Do you engage in regular physical exercise?
 
Do you suffer from any kind of sleeping problems?
 
If yes, what kind of sleeping problems do you have?
Which of the following are part of your dietary habits? (Check all that apply)
   
How often do you snack between meals?
Before eating a meal, you are usually
How much water do you drink in a day, not including water taken near or during meals? (1 Liter = 4 glasses)
How often do you fast?
If you fast regularly, how many times per month do you fast and when was the last time you fasted?
What types of fasting have you experienced? (Check all that apply)
   
How often do you drink alcohol?
How often do you smoke cigarettes?
How often do you take medicines?
Please provide the names of the medicines that you are currently taking?
Have you had any operations?
 
If yes, what kinds of operations have you had?
How often do you have bowel movements (stool)?
Do you have gas problems?
Do you have any allergies?
 
If yes, please list them below:
Do you frequently have body pain?
 
If yes, please describe the types of body pain that you are experiencing?
Please list any stress or emotional issues that you feel may affect your everyday activity and physical health.
Please list any psychoactive drugs you are currently taking.
Please describe any other health problem that you have?
Please provide any other relevant information.
Disclaimer: This health form is not used to diagnose or treat any disease. When making changes to your diet or lifestyle, you are advised to consult with your doctor.

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