Telehealth Initial Health Risk Survey
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone Number
Email
Medical History
Do you have any chronic conditions? If yes, please list.
Current medications (if any)
Lifestyle & Habits
Do you smoke?
No
Yes
Former smoker
Do you consume alcohol?
No
Yes
Occasionally
Physical activity level (e.g., sedentary, moderate, active)
Current Symptoms
Are you currently experiencing any symptoms?
Other health concerns