Healthy History Form

Welcome to your Health History Form

1. Your Name
2. Your Mobile Number
3. History of hearth problems,chest pain or stroke
4. Elevated Blood Pressure
5. Any Chronic Illness or Condition
6. Difficulty with physical exercise
7. Recent Surgery ( e.g. General Operation,C-Section( Cesarean delivery)
8. History of breathing or lung problems e.g. asthmatic
9. Muscle,Joint or Back Disorder  or any previous injury still affecting you
10. Cigarette Smoking Habit
11. Diabetic
12. History of heart problems in immediate family
13. Any Additional Information you would like to add (Comments,Questions,Suggestions)
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