Patient Intake & Health Profile – Hopewell Healthcare

1. Personal & Body Composition

Full Name *

Mobile Number *

Email Address *

Age *

Gender *FemaleMaleOtherPrefer not to say

Country *

BMI (auto-calculated)

Family History

City

Height (cm) *

Unintentional weight change in the last 6 months? *YesNo

Existing Health Concerns *

Has your health worsened in the last 2 years? *YesNo

Current Medications *

Weight (kg) *

Meal timing – breakfast

Hours

Minutes

AM/PM

Water intake (glasses/day)

Work stress *YesNo

Exercise frequency *

Food restrictions / allergies

Meal timing – lunch

Hours

Minutes

AM/PM

Sleep duration (hours) *

Dietary preference *

Financial stress *YesNo

Meal timing – dinner

Hours

Minutes

AM/PM

Sitting hours/day

Family stress *Option 1Option 2

Meal timing – snacks

Hours

Minutes

AM/PM

Health-related anxiety *Option 1Option 2

Anxiety about the future *Option 1Option 2

Commute burden *Option 1Option 2