Employee Health Risk Assessment Questionnaire
Personal Information
Full Name
Email
Age
Gender
Female
Male
Other
Lifestyle
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
How many days per week do you exercise?
Medical History
Do you have any chronic diseases?
Yes
No
If yes, please specify
Do you take any regular medication?
Yes
No
If yes, please specify
Family History
Please list any significant family medical history
Additional Comments