A2 - OptiHealth Team Intake Questionnaire Screen
OptiHealth Team Intake Questionnaire
Enter Participant's Phone #
Phone #
First Name
Last Name
Email
Date-of-Birth
(MM / DD / YYYY)
Age
(YY - MM)
Gender
( Male / Female )
Height
(X - XX)
Weight
(XXX)
Body Mass Index
(XX.X)
CrossComp Score
XXX.X%
Level Participant
Date of CrossComp
Current / Expired
First Name
Last Name
Date-of-Birth
(MM / DD / YYYY)
Age
(YY - MM)
Gender
( Male / Female )
Height
(X - XX)
Weight
(XXX)
Body Mass Index
(XX.X)
CrossComp Score
XXX.X%
Level Participant
Date of CrossComp
Current / Expired
Indicate Chronic Diseases
Overweight
Obese
High Blood Pressure
High Cholesterol
Pre-Diabetes
Type 2 Diabetes
Heart Disease
Vascular Disease
Cancer
Depression
Healthcare
Indicate Family History
( Yes / No )
Describe Unhealthy Lifestyles
Exercise
Nutrition
Sleep
Water
Air
Sunlight
Temperance
Trust
Attitude
Describe Life Experience
Family of Origin
Education
Military
Marital Status
Occupation
Commute
Housing
Child Care
School
Elder Care
Recreation
Entertainment
Family Relations
Friends
Faith
Fellowship
Politics
News Source
Service
Support
Quality of Life
Overweight
Obese
High Blood Pressure
High Cholesterol
Pre-Diabetes
Type 2 Diabetes
Heart Disease
Vascular Disease
Cancer
Depression
Healthcare
Indicate Family History
( Yes / No )
Describe Unhealthy Lifestyles
Exercise
Nutrition
Sleep
Water
Air
Sunlight
Temperance
Trust
Attitude
Describe Life Experience
Family of Origin
Education
Military
Marital Status
Occupation
Commute
Housing
Child Care
School
Elder Care
Recreation
Entertainment
Family Relations
Friends
Faith
Fellowship
Politics
News Source
Service
Support
Quality of Life
Notes:
- X