Clinic Pre-Booking Health Questionnaire
Name
First
Last
Phone
Email
1. What is your primary reason for booking a Clinics on Cloud health assessment?
General health check-up
Corporate wellness screening
Annual health assessment
Monitor an existing health condition
Fitness and wellness tracking
2. Have you had a comprehensive health assessment within the last 12 months?
Yes
No
I'm not sure
3. Do you currently have any diagnosed medical conditions?
High Blood Pressure
Diabetes
High Cholesterol
Heart Disease
Asthma or Respiratory Condition
Kidney Disease
Liver Disease
Arthritis or Gout
None
4. Are you currently taking any prescription medication?
Yes
No
5. Do you have any of the following lifestyle risk factors?
Smoking
Alcohol consumption
Limited physical activity
High stress levels
Poor sleep
Unhealthy diet
Family history of chronic disease
None of the above
6. What health goals would you like this assessment to help you achieve?
Prevent future illness
Improve fitness
Weight management
Monitor blood pressure
Monitor blood sugar
Improve heart health
Improve overall wellness
7. Are you experiencing any symptoms that concern you?
Chest pain
Shortness of breath
Frequent headaches
Fatigue
Dizziness
Joint pain
High stress or anxiety
None
8. Have you ever had an abnormal ECG, blood pressure, blood glucose, cholesterol, or other health screening result?
Yes
No
Unsure
9. Do you understand that Clinics on Cloud is a preventive health screening service and does not replace a consultation with a medical doctor or provide a medical diagnosis?
Yes, I understand.
No, I would like more information.
10. How did you hear about Clinics on Cloud?
Healthi
Employer / Corporate Wellness Day
Friend or Family
Social Media
Website
Google Search
Healthcare Professional
Event or Expo
Confirm1
(Required)
I confirm that the information I have provided is true and accurate to the best of my knowledge.
Confirm2
(Required)
I understand that Clinics on Cloud is a wellness screening tool designed to provide health insights and is not intended to diagnose, treat, or cure any medical condition.
Confirm3
(Required)
I understand that any abnormal findings should be discussed with a qualified healthcare professional.
Confirm4
(Required)
I consent to the collection and processing of my personal information for the purpose of my health assessment in accordance with the Protection of Personal Information Act (POPIA).
Confirm5
(Required)
I agree to the Terms & Conditions and Privacy Policy.
These questions help screen participants appropriately, educate them about what to expect, and support informed consent while also collecting useful information for both individual and corporate bookings.