Health Assessment Form — Health Risk Prediction System

Personal Identification

First Name^*

Last Name^*

Physical Metrics

Age^* 18 – 120 years

Weight^* Kilograms (20 – 300 kg)

Height^* Centimetres (50 – 250 cm)

Calculated BMI

— Enter weight & height above

Auto-calculated from your measurements

Lifestyle Factors

Daily Sleep^* Hours per night (0 – 24)

Exercise Level^* Your typical weekly activity level

Profession^*

Health Behaviours

Do you smoke?^*

Yes No

Do you consume alcohol?^*

Yes No

Marital Status^*

Married Not Married

Used for model accuracy — no suggestions made on this factor