Introduce yourself to your new Health Assistant
We’d love to know more about you. It’ll go a long way in helping us provide care that is tailor-made for you. Go through the questions below and answer them - it’ll take a few minutes, promise!
P.S:
All your details will be kept strictly confidential.
Let's Start
Basic Details
Name
Email
Phone
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Your Date of Birth
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What is your Gender
Male
Female
Other
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Your Height in cm
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Your Weight in kg
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Waist Circumference(cm)
PS: You may need a measuring tape to measure your waist circumference
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Medical History
Have you ever been diagnosed with
Pre-diabetes (HbA1c: 5.8%-6.4%)
Diabetes (HbA1c: >6.5%)
Pre-Hypertension (BP: >120/80 but <140/90)
Hypertension (BP: >140/90)
None of the above
This field id required
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What is your last known HbA1c value?
I don't remember
Above fields are required Kindly fill any one
What is your last known BP value? (Systolic and Diastolic )
I don't remember
Above fields are required Kindly fill any one
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How long have you been diagnosed with this condition?
Less than 3 months
3 months - 2 years
2 years- 5 years
5 years- 10 years
Over 10 years
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Do you have a family history of chronic diseases such as Hypertension, Diabetes, Thyroid Disorders, and Obesity
Yes
No
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Which of the following chronic disease does your family member suffers from
Diabetes
Hypertension
Obesity
Thyroid Disorders
None of the above
This field is required
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Have you experienced any complications with your disease?
Numbness, tingling, burning sensation in feet
Blurry Vision (Retinopathy)
None till now
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Are you taking any injectable medications?
Yes
No
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How many medicines do you take apart from injectable medicines?
None
1-2 tablet
3 tablets
More than 3 tablets
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Personal LifeStyle
How often do you exercise?
Daily
Couple of times a week
Once a week
Infrequent
None
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How many hours of sleep do you get every night?
Less than 5 hours
5-7 hours
7-9 hours
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How is the quality of your sleep?
Excellent
Good on most nights
Disturbed sleep on almost every night
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How are your eating habits?
Home cooked food with fruits and salads
Home cooked food only
Home cooked most days with occasional outside food
Outside food at least once a week
Outside food almost daily
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I believe that my knowledge of my condition is
Poor
Brief
Good
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My knowledge on the food I eat is
Poor
Brief
Good
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How often do I monitor my vitals? (BP or Blood Sugar)
Never
Few times a month
Multiple times a week
Daily
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I meet my care provider
Not unless urgent
Once a year
Once in 6 months
Once in 2-3 months
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My motivation to get better in regard to my condition is
Very strong, I will do whatever it takes
Strong, I do want to take things in my hands
Neutral, I would like to get better
Not motivated, I feel comfortable and don't foresee things getting worse
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My expectation from this program is
Bring my readings to normal levels
Get fitter and healthier
Reduce the number of medications
Prevent any complications
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Thank you for sharing your information. Your Health Coach will soon get in touch with a personalised care plan. Here’s to your best health!
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