Personal Information (1/4) ^*

First Name ^*

Last Name ^*

press Enter ↵

'Oops! something went wrong.',

Personal Information (2/4) ^*

Email ^*

Phone Number ^*

press Enter ↵

'Oops! something went wrong.',

Personal Information (3/4) ^*

Sex at birth

press Enter ↵

'Oops! something went wrong.',

Personal Information (4/4) ^*

Your Weight(with Unit),

press Enter ↵

'Oops! something went wrong.',

Personal Information (4/4) ^*

Your Height(with Unit),

press Enter ↵

'Oops! something went wrong.',

Personal History (1/3) ^*

Are you prone to any of the following?

Nut Allergy

Pollen Allergy

Sinus Allergy

None of the above

press Enter ↵

'Oops! something went wrong.',

Personal History (2/3) ^*

Do you currently have or in the past have a history of the following?

Hypertension (BP)

Diabetes

Heart Problem

None of the above

press Enter ↵

'Oops! something went wrong.',

Personal History (3/3) ^*

Are you allergic to any medications? If so please list them out:

press Enter ↵

'Oops! something went wrong.',

How do you rate your diet? ^*

Healthy – I prioritize balanced meals with nutritious foods.

Moderate – I try to eat well but have occasional indulgences.

Unhealthy – My diet consists mostly of processed or fast foods.

press Enter ↵

'Oops! something went wrong.',

How is your sleep schedule?  ^*

7 hours or more

6-7 hours

Less than 6 hours

press Enter ↵

'Oops! something went wrong.',

Do you currently smoke or use tobacco products? ^*

No, I do not smoke or use tobacco.

I have smoked in the past. Not anymore.

Occasionally – I smoke or use tobacco products occasionally.

Yes, regularly – I smoke or use tobacco products daily.

press Enter ↵

'Oops! something went wrong.',

Describe your alcohol consumption? ^*

Never drink – I have never consumed alcohol.

Used to drink – I previously consumed alcohol but no longer do.

Social drinker – I drink occasionally in social settings.

Heavy drinker – I consume alcohol frequently or in large amounts.

History of alcoholism

press Enter ↵

'Oops! something went wrong.',

Family History

Do any of your blood relatives have any other medical condition besides those already mentioned ? If yes, Please mention the condition:

press Enter ↵

'Oops! something went wrong.',

Recent History (2/11) ^*

Mark any of the following Gastrointestinal conditions you have been diagnosed with in the past:

GERD

Gastrointestinal Bleeding

IBS

Crohn's Disease

Stomach Ulcers

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (3/11) ^*

Mark any of the following neurological conditions you have been diagnosed with in the past:

Multiple sclerosis

Seizures

Balance Disorder

Peripheral Neuropathy

Head Injury

Migraine

Headaches

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (4/11) ^*

Mark any of the following Urological conditions you have been diagnosed with in the past:

Chronic Kidney Disease

Kidney Stones

Urinary Incontinence

Dialysis

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (5/11) ^*

Mark any of the following ENT conditions you have been diagnosed with in the past:

Glaucoma

Vertigo

Hearing Problems

Nosebleeds

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (6/11) ^*

Mark any of the following endocrinological conditions you have been diagnosed with in the past:

Hypothyrodism

Hyperthyroidism

Diabetes

None of the above

press Enter ↵

'Oops! something went wrong.',

If you have been diagnosed with diabetes in the past, please specify the type:

press Enter ↵

'Oops! something went wrong.',

Recent History (7/11) ^*

Mark any of the following psychological conditions you have been diagnosed with in the past:

Depression

Anxiety

ADD/ADHD

Schizophrenia

PTSD

Bipolar Disorder

None of the above

press Enter ↵

'Oops! something went wrong.',

If you have been diagnosed with any other psychological condition, please specify the type:

press Enter ↵

'Oops! something went wrong.',

Recent History (8/11) ^*

Mark any of the following Respiratory conditions you have been diagnosed with in the past:

Asthma

Bronchitis/Pneumonia

Emphysema/COPD

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (9/11) ^*

Mark any of the following Musculoskeletal/Rheumatologic conditions you have been diagnosed with in the past:

Bursitis

Osteoarthritis

Osteoporosis

Fibromyalgia

Carpal Tunnel Syndrome

Rheumatoid Arthritis

Chronic Joint Pains

None of the above

press Enter ↵

'Oops! something went wrong.',

Recent History (10/11) ^*

Mention if you have been diagnosed with cancer in the past. If yes, please specify: type of cancer, site or organ involved (if applicable), year of diagnosis, stage (if known) and current status (e.g., under treatment, in remission, cured).

press Enter ↵

'Oops! something went wrong.',

Recent History (11/11) ^*

Mention if any Other Medical Condition that you have been diagnosed with in the past:

press Enter ↵

'Oops! something went wrong.',

Medication History ^*

Are you currently on any medication? If yes, please list below:

press Enter ↵

'Oops! something went wrong.',

Do you feel pain in any area besides those already mentioned?

If yes, Please specify

press Enter ↵

'Oops! something went wrong.',

Activity History ^*

Do you exercise?

Negligible and/or only walking

Moderate

Intense, but only cardio

Intense, both cardio and resistance training

press Enter ↵

'Oops! something went wrong.',

Are there any specific health concerns you're hoping to get more information about during the scan?

press Enter ↵

'Oops! something went wrong.',

Disclaimer ^*

Your health and privacy matter to us. By signing this form, you acknowledge that you have read, understood, and agree to be bound by the terms outlined in the Privacy Policy and Terms & Conditions. With your electronic signature, you provide informed consent, ensuring a seamless and secure experience for your proactive health screening with EVO360.
Privacy Policy
Terms & Conditions

press Enter ↵

'Oops! something went wrong.',

Thank you!

Create your own Youform

Welcome back! Loading your previous answers...

Help Evo360 understand you better

Thank you!