Health-Risk-Assessment First Name *Age *Weight *Height *Waist Size *Dietary assessment-What are your dietary preference?VegetarianNon-VegetarianVeganEggetarianWhat is your dietary restrictions?Low FatLow SaltDiabeticLactose IntolerantGluten SensitiveNoneHow many portions of fruits and vegetables do you eat in a week?0-1servings2-4 servingsMore than 4 servings How many times in a week do you eat foods or drinks that are high in sugars or unhealthy fats?0-1servings2-4 servingsMore than 4 servings On an average how much water do you drink in a day?Less than 1 L1-2 L2-4LMore than 4 LIn the last 7 days, how often did you exercise? Never1-2 times in a week3-6 times in a weekEverydayHow many minutes per day do you engage in physical activity?Less than 20 min20-30 min 30-60 min More than 60 How many hours do you spend sitting at work or at home?1-2 hours3-5 hours6-8 hours More than 8 hoursHow many hours of sleep do you get?Less than 5 hours 6-8 hours More than 8 hours Do you feel fresh when you wake up in the morning?NeverSometimesAlwaysIn the last 30 days have you smoked or used tobacco?YesNoIf YES, Do you want to quit smoking or using tobacco? Yes I am working on quitting or cutting back right now NoIn the last 7 days, how often did you have (5 or more for men, 4 or more for women) alcoholic drinks at one time? (1 drink is 1 beer, 1 glass of wine, or 1 shot).NeverOnce in a week2-3 times in a week.More than 3 times in a weekHow often is stress a problem for you in handling everyday things such as your health, money, work, or relationships with family and friends? Almost every day Sometimes RarelyNeverHow do you manage to control your stress levels?YogaMeditationSocialisingOthersNilHow often do you spend time on computer, TV, mobile or other electronic gadgets?NeverRarelyVery OftenAlwaysDo you have any of the medical condition?DiabetesHypertensionHypo or HyperthyroidArthritisHigh LipidsAsthmaHeart ProblemsAre you on medication?YesNoWhat is your employment status?Working from officeWorking from homeStudentHomemakerRetiredSubmit
