KCMINC

K.C. Morris Inc

BOLA

Health Survey

Complete the form below to receive your health report. Your privacy is our priority; we use HIPAA's de-identification standards to ensure the information you provide is completely anonymous and untraceable.

Section 1 of 2

Personal Information

Enter your age ⦁
Enter your height in feet ⦁
Enter your height in inches ⦁
Enter your weight in pounds ⦁
Select your gender ⦁
Select your lifestyle:
Do you drink alcohol?
Do you use nicotine?

Section 2 of 2

Health Questions

Have you experienced any significant changes in your appetite, energy levels, sleep patterns, or any unexplained fevers or weight changes?
Do you have a history of high blood pressure, high cholesterol, or heart disease? Are you experiencing any chest pain, palpitations, shortness of breath, or swelling in your legs?
Do you have a history of asthma, COPD, or smoking? Have you had any persistent cough, wheezing, or difficulty breathing with activity?
Have you had any persistent heartburn, abdominal pain, bloating, difficulty swallowing, or any major changes in your bowel habits (e.g., diarrhea, constipation, blood)?
Do you have a history of migraines, seizures, or stroke? Have you experienced any severe headaches, dizziness, numbness, tingling, weakness, or changes in memory or balance?
Do you have a history of arthritis or major injuries? Are you having any significant muscle weakness, back pain, joint stiffness, swelling, or limited range of motion?
Do you have a personal or family history of skin cancer? Have you noticed any new or changing moles, sores that won't heal, unusual rashes, or lumps?