Surveypoint

Q1

Who is filling this form?

Patient

Parent

Other

Q2

First Name

Name of Patient

Q3

Last Name

Name of Patient

Q4

Date of Birth of Patient

Q5

Do you have one of the following conditions?

Yes

No

Any medications used

Diabetes

High Blood Pressure

High Cholesterol

Depression

Shortness of Breath

Q6

Weight of Patient

Q7

Hight of Patient

Q8

Does patient have regular exercise habit?

Yes

No

Q9

Does patient expose with smoke or vape?

Yes

No

Q10

Does patient get help from psychological consulting?

Yes

No

Q11

Does patient have appetite?

Yes

No

Q12

Does patient have allergies?

Yes

No

Q13

How much caffeine patient consume?

None

1 cup

1-3 cups

More than 3 cups

Q14

Does patient have any following nonspecific symptoms?

Weight loss

Headache

Chronic pain

Fatigue

Night sweats