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Track your personal wellness
Begin by filling-out your wellness check-up
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HIPAA
Compliance
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English (US)
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Italiano
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Korean
Filipino
Ukrainian
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Portuguese (Portugal)
Japanese
German (Germany)
Polski
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1
Full Name
First Name
Last Name
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2
What is your gender?
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3
What is your age?
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4
Contact Number
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5
Email Address
example@example.com
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6
What is your height?
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7
What is your weight?
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8
What is your resting Target HR?
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9
What is your oxygen saturation?
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10
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
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11
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
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12
Are you currently taking any medication?
Yes
No
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13
Please list them.
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14
Do you have any medication allergies?
Yes
No
Not Sure
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15
Please list them.
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16
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
Yes
Please Select
Yes
No
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17
What kind of tobacco products? How long have you used/been using them?
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18
Do you have any concerns in your sleep routine? Do you have difficulty falling asleep?
Please Select
Yes
No
No
Please Select
Yes
No
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19
During the past month have you often been bothered by feeling down, or hopeless?
Yes
No
No
Yes
No
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20
During the past month have you felt little interest or pleasure in doing things?
Yes
No
No
Yes
No
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21
Is this something which you would like help with?
Yes - but no today
No
No
Yes - but no today
No
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22
During you feel you have a hearing loss?
Yes- Perform Calfrast
No
No
Yes- Perform Calfrast
No
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23
Do you have difficulty with vision or do you feel that you need to see an eye specialist?
Yes- Perform Calfrast
No
No
Yes- Perform Calfrast
No
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24
Do you perform a regular physical activity ?
Yes
No- are you willing to increase your physical activity?
Yes
No- are you willing to increase your physical activity?
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25
Do you perform regular stretching?
Yes- Perform Calfrast
No
No
Yes- Perform Calfrast
No
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26
Do you perform meditation?
Yes- Perform Calfrast
No
No
Yes- Perform Calfrast
No
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27
Do you take drugs (food supplements and vitamins are not included) that are not prescribed by medical doctors? What kind of drugs? How long have you used/been using them?
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28
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
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29
File Upload
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Please upload the filled-out form SF-12
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30
Signature
My signature attest that the information is true to the best of my knowledge. I also consent to submit my information for wellness screening.
Clear
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