Chronic Disease Self-Check Form
Full Name
Age
Gender
Female
Male
Other
Prefer not to say
Chronic Disease History
Have you been diagnosed with any of the following chronic diseases?
Diabetes
Hypertension
Asthma
Heart Disease
Kidney Disease
Other
None
If diagnosed, for how many years have you had the disease(s)?
List your current medications
Recent Symptoms
Are you currently experiencing any of these symptoms? (Check all that apply)
Shortness of breath
Chest pain
Fatigue
Swelling (ankles, feet, hands)
Frequent urination
Unexplained weight change
None
Other symptoms (please specify)
Lifestyle & Monitoring
How often do you monitor your condition?
Daily
Weekly
Monthly
Rarely
Additional remarks