Health & Lifestyle Questionnaire

Healthy Lifestyle

By answering the following questions, this Health & Lifestyle Questionnaire becomes a tool to help you better understand your own lifestyle and its affects on your health. The questionnaire provides you with a starting point to act as a guide to help you make new and healthy lifestyle changes.

This questionnaire is only a rough screening for heart disease which helps in self-assessment and elicits the need to take precautionary measures for preservation of good health.

  • 01

    How old are you?


  • 02

    Are you male or female?


  • 03

    How would you describe you body and physical condition?


  • 04

    How many members of your family have a history of heart disease?


  • 05

    How often do you eat-out, consume junk food and fast-food?


  • 06

    In general, which type of foods do you mostly like to eat?


  • 07

    Do you a smoke cigarettes or have you used tobacco related products in the past?


  • 08

    Are you physically active and exercise regularly or do you have no exercise or irregular physical activity?


  • 09

    Have you had you blood cholesterol checked recently?


  • 10

    Have you had you blood pressure checked recently?

    Systolic Blood Pressure in mm/Hg



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Health & Lifestyle Questionnaire
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Contact Information

Dr. Manisha Bandishti
Lifestyle for Health

303, 3rd floor, Choice ‘C’ Apartment
Opposite Millenium Star Building
Near Ruby Hall Clinic
Dhole Patil Road
Pune-411001
India

T: 020 26161095
M: 7350530101
E: info@drmanishabandishti.com