Personal & Family Health
Information Form (PFHI)

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General Medical Information

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(Tick if appropriate)

How often do you experience Stress

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Lifestyle Profile

Stimulant Consumption Frequency

Stimulant Frequency

Yes

Sleep

(Hours per Day:

)

Sleep Quality

Tick if appropriate

Activity Levels

Physical Activity

Steps

Tick if appropriate

Health checks*

Health Seeking Behavior

Tick if appropriate

Results/Latest test date if Yes

Report Copy if Yes

Attached document

Other test if any:

Any other personal lifestyle information that you would like to add/explain:

Nutrition Profile

Food Intorlerance

(Tick on appropriate)

Do you experience nausea, bloating, diarrhea, or discomfort on consuming

Food Item

Diet Patterns

(Tick on appropriate)

Dietary Habbit

Explanation

Diet Composition

How often do you consume

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Food additives (Salt/Sugar/Oil)

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(Tick on appropriate)

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(Tick on appropriate)

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Any other personal nutritional information that you would like to add/explain:

2 Family Health Information

In the following table, you are requested to add health historyof your family members. To add the same, please tick wherever applicable and add age on onset(age of diagnosis).

Relationship	Parents	Siblings	Children
Conditions	{{member.member}}
{{conditionType.title}}
{{conditionValue}}	Onset Age

Primary reason for you to take this test

The PFHI form has been successfully updated.

To proceed to dashboard click here :

Personal medical history
Disease	Onset Age	Medication

Personal surgical history
Disease	Onset Age	Surgery

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1

Personal Health Information

2

Family Health Information