HUMANET.IO

#	Question	Yes	No
1	Have you experienced any abnormal weight gain or loss (more than 20 kg) over the last 6 months?
2	Do you smoked more than 20 cigarettes (average) a day over the last year?
3	Do you drink more than 20 glasses (average) of alcohol (beer/wine/whisky etc.) in a week?
4	Have you ever taken drugs, narcotics, sniffed glue or been treated for drug addiction?
5	Have you ever been diagnosed with HIV or Hepatitis A – B or C?
6	Has any of your parents/siblings suffered from cancer, stroke, heart, liver or kidney disease?
7	Are you currently suffering from; Diabetes, Hypertension or Hyperlipidaemia?
8	Do you have any diabetic related complications such as amputation, kidney failure, coma, etc.?
9	Do you have dental issues involving your teeth, gums or cavities?
10	Do you wear any type of dentures (PUSTISO) removable or fixed?
11	Your Height?		cm/inch
12	Your Weight?		lbs/kg
#	Question	Yes	No
13	Are you taking medications regularly?
14	Are you currently attending a hospital/GP for treatment or waiting for an appointment?

#	Question	Yes	No
1	Asthma
2	Bronchitis
3	Pneumonia
4	Emphysema
5	Pleurisy
6	Pneumothorax
7	Tuberculosis
8	Cough
9	Hemoptysia
10	Epistaxis
11	Difficulty Breathing
12	Are you using Oxygen tank?

PART D: GASTRO-INTESTINAL SYSTEM RELATED HEALTH PROBLEMS

#	Question	Yes	No
1	Do you have Recurrent Dental, oral, Nausea, Dyspepsia or Dysphagia?
2	Do you have Recurrent Heartburn, Indigestion or Hiatus Hernia?
3	Gastric, Duodenal or Peptic ulcer?
4	Do you have Abdominal pain?
5	Diarrhea or Vomiting lasting more than one week?
6	Do you have any abdominal Hernia?
7	Gastro-intestinal or Rectal bleedings?
8	Irritable Bowel Syndromes?
9	Crohn’s Disease?
10	Ulcerative Colitis?
11	Jaundice or Problems with Gallbladder?
12	Any form of hepatitis or other liver problem?

#	Question	Yes	No
1	Any weight or appetite changes
2	Do you have Diabetes
3	Any Thyroid Disfunction
4	Any Adrenal Gland Disease
5	Do you have any auto-Immune illness related problems?

PART F: SKIN RELATED HEALTH PROBLEMS

#	Question	Yes	No
1	Do you have any allergies or Urticaria?
2	Do you have Psoriasis?
3	Do you Have Eczema?
4	Do you have Allergic dermatitis?
5	Do you have any skin infections?
6	Do you have vetiligo?
7	Do you have tendency to skin cancer?
8	Do you have allopecia?

#	Question	Yes	No
1	Do you have bones or joints pain, dislocation or swelling? If yes please indicate below.
2	Neck
3	Back
4	Shoulder
5	Elbow
6	Handled
7	Hip
8	Knee
9	Ankle
10	Have you been diagnosed as having arthritis, gout, or rheumatism?
11	Do you have Sciatica?
12	Do you have Osteoporosis or recurrent fractures?

#	Question	Yes	No
1	Do you have headaches, migraines, vertigo, dizziness, giddiness or problems with balance?
2	Do you have any diseases of the nervous system like, neuritis, stroke or multiple sclerosis?
3	Did you had any Head injuries leading to loss of consciousness requiring hospital admission?
4	Do you have Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
5	Do you have any limb motor or sensory symptoms or loss of coordination?
6	Do you have any visual defect e.g., scotoma, blindness in one eye, night blindness, blindness, color blindness, reduced visual field, blurred vision or detached retina?
7	Do you have any eye disease or conditions such as glaucoma or retina issues?
8	Did you had any Injury or surgery to your eye(s) including laser eye surgery?
9	Do you have or had any Ear infection, discharge, tinnitus, a hearing defect including deafness?
10	Do you have issues with Speech and related functions like reading and writing skills and memory?
11	Do you have any defect in your testing and smelling abilities?

#	Question	Yes	No
1	Do you have Anxiety/Depression, phobias, mental breakdown or stress related problems?
2	Do you have any Mental Illness and / or cognitive disorders, such as: Alzheimer or Dementia?
3	Do you have any disorders affecting learning, memory, perception and problem solving?
4	Do you have any eating disorder e.g., anorexia nervosa or bulimia?
5	Do you suffer from Substance misuse?
6	Do you have sleeping disorder?

#	Question	Yes	No
1	Frequency in urination
2	Pain with micturition
3	Urethral Discharge
4	Blood or change of urine color
5	Kidney stones
6	Urgency in Urination
7	Incontinence
8	Recurrent kidney or urinary tract infection
9	Cystitis
10	Urethritis

#	Question	Yes	No
11	Any issues with the Prostate?
12	Any testicular issues?
13	Any actual or previous sexually transmitted infection?
14	Any sexuality issues, problems with erection etc.?

#	Question	Yes	No
11	Any problem with the menstruation?
12	Are you in Menopause phase?
13	Are you aware of, any breast lumps or disorder?
14	Any family members been diagnosed with breast cancer?
15	Are you aware of any disorder with ovaria or uterus: fibroid, cyste, polyps?
16	Any abnormal pap smear test?
17	Any complications during any of your pregnancies such as gestational?