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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Date
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Gender
Male
Female
Other
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Height(cm)
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Weight(kg)
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Waist Circumference
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Medical History
Are you 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)
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What is your last known HbA1c value? (for Diabetics)
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What is your last known BP value? (for Hypertensive)
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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 any family history of chronic diseases (Hypertension, Diabetes, Thyroid Disorders)?
No one in my family or relatives is affected
Yes, my first degree family member(s) are affected (mother, father, siblings)
Yes, my extended family member(s) are affected (grandparents, uncles, aunts, cousins)
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Do you have any other associated diseases?
Diabetes or Hypertension
Elevated Cholesterol Levels
Thyroid Dysfunction (Hypo or Hyper)
Hormonal Disorders (PCOS, Infertility, etc)
Vitamin Deficiency
None, I'm all good!
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Have you experienced any complications with your disease?
Fatty Liver
Numbness, tingling, burning sensation in feet
Kidney Dysfunction (Elevated Creatinine, Urine Protein)
Blurry Vision (Retinopathy)
Heart Dysfunction
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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Self Care and Knowledge
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 levels? (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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