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Health Assessment

Please complete the form

Get a comprehensive overview of your health with our easy-to-complete Health Assessment Form, designed to help identify key areas for improvement and guide your wellness journey.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Weight (kg)(Required)

Height (cm)(Required)

Blood type (eg)

How much water do you drink per day?(Required)

2 glasses

5 glasses

8 glasses

How much alcohol do you drink per week?

None

2 glasses

6 glasses

More

Rate your quality of sleep:(Required)

Poor (3-5 hrs per night)

Fair (6-7 hrs per night)

Good (7-9 hrs per night)

How often do you exercise per week?(Required)

2+ Days

4+ days

6+ days

Never

Overall, how would you rate your health?(Required)

Excellent

Good

Fair

Poor

Do you have any Chronic illness? If Yes, please list below(Required)

Convenience and Easy Access at your Fingertips

Well2care Client Service

Call: +27 082 820 1813

Email: well2care@abovax.com

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