Nutritionist Seema Singh

ANAEMIA RISK ASSESSMENT FORM

AGE

HAEMOGLOBIN

SMOKING

What kind of food you eat?

ACTIVITY LEVEL (aerobic exercise, at least 30 minutes per session)

Are You Pregnant?

Do You Have Alcohol History?

Do You Have any past Medical history?

Do you have any surgical history?

Do you have any family history of following?

Have you experienced any of the following?

BODY MASS INDEX

Have you experienced heavy or prolonged menstrual bleeding recently?

Have you noticed any bowel changes recently, particularly darker or more offensive smelling tools?

Do you suffer from gastrointestinal reflux disease or peptic ulcer disease?

Thank you for taking our survey.

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