Create Survey | Samarppanam

Participate in our Survey

First Name*

Last Name

Phone Number*

Email Address*

Age

Height (cm)

Weight (Kg)

BMI

Address

1. Do you have high blood pressure?*

Yes No

2. Do you smoke?*

Yes No

3. Do you have high cholesterol?*

Yes No

4. Do you eat fast food / Fried foods on a regular basis?*

Yes No

5. Do you Eat more than 5 servings of fruit a week?*

Yes No

6. Do you have vegetables more than 3 times a week?*

Yes No

7. Do you exercise regularly?*

Yes No

8. Do you drink Alcohol?*

Yes No

9. Do you chew tobacco?*

Yes No

10. Have you had a stroke?*

Yes No

11. Has anyone in your family had a heart attack / Stroke?*

Yes No

12. Do you have heartburn?*

Yes No

13. Do you have chest pain when walking, climbing stairs, or during anxiety?*

Yes No

14. Do you have trouble breathing while walking?*

Yes No

15. Have you had paralysis / Stroke / heart attacks, which occurred within the last one year?*

Yes No

16. Do you have diabetes ?*

Yes No

17. Has body weight increased recently?*

Yes No

18. Did you have sudden loss of consciousness, epilepsy?*

Yes No

19. Do you see Blood in urine?*

Yes No

20. Have you lost more than 5 kilograms of body weight in the past 6 months?*

Yes No

21. Do you have blood stained sputum?*

Yes No

22. Is there a blood trace in the stool?*

Yes No

23. Do you have any swelling in the neck or breast?*

Yes No

24. Has anyone in the family had cancer?*

Yes No

25. Do you have recurrent severe abdominal pain?*

Yes No

26. Do you have difficulty in swallowing?*

Yes No

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