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

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)

info@well2care.com

Well2Care

Call: +27 082 820 1813

info@well2care.com

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