Full Name*

Clinic name*

Patient ID*

Ethnicity*

Date of Birth*

Sex*

Male

Female

Intersex

Prefer not to say

Height*

Weight*

Would you say that in general your health is...*

Do you have any allergies?*

Yes

No

Maybe

Have you had cavities, gingivitis or periodontitis within the past year?*

Yes

No

Within the past 2 months, have you had gastrointestinal conditions or discomfort, such as bad breath, gastric acidity, flatulence and / or feeling bloated after a meal, diarrhea, very soft stools, constipation or hemorrhoids?*

Yes

No

If you answered yes, please list which one you had:

Do you frequently have musculoskeletal pain?*

Yes

No

Within the past 2 months have you had memory problems, mood swings, felt depressed or anxious?*

Yes

No

Do you have any diagnosed medical condition?*

Yes

No

If you answered yes, feel free to be specific:

Have you previously used tobacco or e‑cigarettes?*

Yes

No

Do you currently use tobacco or e‑cigarettes?*

Yes

No

Have you ever been diagnosed with, or treated for, any of the following conditions?*

If you answered any question with yes, do you take any medications for your illness/es?

Yes

No

Please list your medication

On average how much sunlight exposure you get daily?*

Less than 30 mins

1h

2h

3h or more

	Yes	No
Lupus
Rheumatoic Arthritis
Multiple Sclerosis
Immunodeficiency
Diabetes
Thyroid Disease
Heart Failure
Coronary Artery Disease

Lifestyle Questionnaire

Lifestyle Questionnarie