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Personalized Wellness Plan Questionnaire
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Do you have any existing medical conditions?
Please specify if you have any medical conditions such as diabetes, hypertension, or asthma
Yes
No
2
Are you currently taking any medications?
List any medications you are currently taking
3
Do you have any allergies?
Specify if you have any allergies
Yes
No
4
Name
Please enter your name
5
Age
Please enter your age
6
Gender
Please select your gender
Male
Female
Other
7
Height
Please enter your height in centimeters
8
Weight
Please enter your weight in kilograms
9
Email
Please enter your email address
10
Phone Number
Please enter your phone number
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