HEALTH QUESTIONNAIRE

 

 

HEALTH QUESTIONNAIRE

Name & Surname:

Number of children: ………….

Male  / Female

Ages: ………….. ………….. ………….. …………..

Living circumstances:
Living with spouse/partner Living alone
Living with family relatives(s)

Current blood pressure
(if known)? ………………………………

Height: (cm / metres / feet) …………………………………….

job description:

Reason(s) for completing the questionnaire today:

How long have you had this?

Health conditions / symptoms you are seeking support for:

1.

2.

3.