Review Of Symptoms And Health Behaviour

Health Assessment Form

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Patient Information

First Name *

Last Name *

Email *

Medical Symptoms Questionnaire

Rate each symptom based on your typical health profile for the last 30 days

0 = Never 1 = Occasionally / Not Severe 2 = Occasionally / Severe 3 = Frequently / Not Severe 4 = Frequently / Severe

Total Symptom Score

out of 284 possible

Health Behaviour Assessment

Meals and Snacks

Number of meals per day (excluding snacks)

Number of snacks per day

Breakfast (list all foods/drinks)

Lunch (list all foods/drinks)

Dinner (list all foods/drinks)

Snacks (list all foods/drinks)

Sleep

Sleep quality (1 = Bad, 10 = Excellent)

Average hours of sleep per night

First food/drink intake (time)

Last food/drink intake (time)

Movement & Activity

Daily step count

Moderate exercise 150-300 min/week?

Vigorous exercise 75-150 min/week?

Relaxation Response time per week (minutes) Mindfulness, meditation, deep breathing, etc.

🕐 Sedentary Time Risk Calculator

Select the hours you spend sedentary during different activities throughout your day

Eating breakfast (hours)

Commuting (car/bus/train)

Desk/computer work

Eating lunch

Reading

Phone/tablet use

Eating evening meal

Socializing (e.g., cafe)

Gaming

Meetings or classes

Relaxing (e.g., hobbies)

Other sedentary activities

I exercise about 1/2 hour to an hour daily

Longest time sedentary without interruption (hours)

Total Sedentary Hours

0.0

hours per day

Health Risk Level

Blood Pressure (Last Week)

Systolic (upper number)

Diastolic (lower number)

Pulse rate

Additional Information

I drink more alcohol now than one year ago

Major life event in last few weeks?

If yes, briefly describe

COVID-19 infection history

Medications & Supplements

List current medications and supplements

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📋 Health Assessment Form

Patient Information

Medical Symptoms Questionnaire

Total Symptom Score

Health Behaviour Assessment

Meals and Snacks

Sleep

Movement & Activity

🕐 Sedentary Time Risk Calculator

Blood Pressure (Last Week)

Additional Information

Medications & Supplements

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