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MyPH HealthChek© & Free HealthChek© are copyrighted Service-marks of
My Preventive Health, LLC
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Our MyPH HealthChek©team will need some basic information such as your age group and your sex in or to help you. For example, the Preventive Health suggestions given to a 50 year old Female may be different than those given to a 20 year old male. Please provide the following information.
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1. What is your Age Group?
10–19
20–29
30–39
40–49
50–59
60–69
70-79
80-89
90+ |
2. What are your main reasons for wanting to improve your health?
I want to take better care of my health
I am feeling my age
I am afraid of Cancer
I am concerned about my looks
I have a bad family history of disease |
3. What is your goal in looking for a Preventive Health program? - Check
all that apply.
I want to Look better.
I want to Feel better.
I want to Lose weight.
I want to Live longer.
I want to Avoid Cancer. |
4. How soon would you like to achieve your goal of improving your health?
6 Months
1 Year
2 years
5 years |
5. Do you have a history of Migraines or frequent Headaches that requires you to take medicines to get some relief?
a. Recurrent Migraines:
Yes
No
b. Headaches that require Medicine
Yes
No |
6. Do you have any Gum infections (gingivitis), Dental Cavities or Silver Fillings of your Teeth?
a. Gum Infections or Dental Cavities:
Yes
No
b. Silver Fillings in your Teeth:
Yes
No |
7. Do you take Thyroid Medicines or have you ever had a diagnosis of Thyroid problems?
a. Take Thyroid Medicines:
Yes
No
b. Diagnosis of Thyroid Problems:
Yes
No |
8. Do you have Asthma, Chronic Lung infections or any type of chronic Lung
Disease (COPD)?
a. Asthma:
Yes
No
b. Lung infections:
Yes
No
c. Chronic Lung Disease (COPD)?
Yes
No |
9. Do you smoke now?
Yes
No |
10. You have quit smoking but you have smoked for more than 10 years total in the past?
N/A
Yes Quit, but smoked more than 10 years
No |
11. Do you have Hypertension (high blood pressure)?
Yes
No |
12. Are you being treated for Hypertension?
Yes
No |
13. Do you have Diabetes (high blood sugar)?
Yes
No |
14. Do you have a Family History of Diabetes?
Yes
No |
15. Have you ever had a Heart attack?
Yes
No |
16. Are you being treated for heart problems now?
Yes
No |
17. Do you have any type of Cancer now?
Yes
No |
18. Have you ever been treated for any type of Cancer?
Yes
No |
19. Do you suffer from acid reflux disease (GERD) or Stomach ulcers?
a. Acid reflux (GERD):
Yes
No
b. Stomach ulcers:
Yes
No |
20. Do you suffer from repeated urinary tract infections or any type of Kidney problem?
a. Recurrent Urinary tract infections:
Yes
No
b. Kidney problem:
Yes
No |
21. Do you have constipation, repeated bouts of Diarrhea or have seen blood in your bowel movements (on toilet paper or in toilet bowl)?
a. Constipation:
Yes
No
b. Diarrhea:
Yes
No
c. Blood in bowel movements:
Yes
No
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Yes
No |
23. Do you suffer from Arthritis or chronic joint pain?
a. Arthritis:
Yes
No
b. Chronic joint pain:
Yes
No |
24. Have you been diagnosed with hepatitis or any type of chronic infection (bacterial or viral)?
Yes
No |
25. Are you overweight for your height? 
Normal for height
Less than normal for height
Overweight by less than 25 lbs?
Overweight by 26 to 50 lbs?
Overweight By 51-100 lbs
Overweight by more than 100 lbs |
26. Are you having Excess Stress on your Job, at Home, or with your Spouse (husband, wife or partner)?
a. Excess Stress at Home:
Yes
No
b. Excess Stress at Job/ Work:
Yes
No
c. Excess Stress from your Spouse:
Yes
No |
27. On average, how many hours of sleep do you get each night?
I get 8 hrs or more
I get 6 to 8 hours
I get less than 6 hours |
28. Do you get at least 30 minutes of vigorous exercise every day?
Yes
No |
29. Have you had a recent diagnosis of Anemia or ‘Low Blood’?
Yes
No |
30. Do you have a strong Family History of Cancer, Diabetes or Heart Disease? - Check
all that apply.
a. Family History of Cancer:
Yes
No
b. Family History of Diabetes:
Yes
No
c. Family History of Heart Disease:
Yes
No |
31. Do you take Vitamins and/or Nutritional Supplements on a daily basis?
Yes
No |
32. Do you take Aspirin or prescription Blood Thinners on a daily or regular basis?
a. Aspirin:
Yes
No
b. Prescription (Rx) Blood Thinners
Yes
No |
33. Are you currently taking any type of Male or Female Hormones?
Yes
No |
34. Do you take Prescription Medicines on a daily basis?
Yes
No |
35. If you take Prescription Medicines, how many Medicines do you take each day?
N/A
1 to 2
3 to 5
6 or more |
36. Have you had recent problems with your Memory?
Yes
No |
37. Do you normally drink filtered water or tap water?
Filtered Water
Local city Tap Water
Unfiltered Well Water |
38. Has your sexual energy decreased over the past several years?
About the same
Has decreased
Has increased
No sexual energy |
39. Do you currently have Health Insurance for you and your family?
Yes
No |
40. Do you have financial pressures in your life right now?
Yes
No |
41. Where have you lived most of your life?
In or near a Large City
In or near a Small City
In the Suburbs
In the Countryside |
42. How do you normally get to your office or your workplace?
I commute more than One Hours
I commute Less than One Hour
I walk or Bicycle to Work
I normally work from Home |
43. Do you drink 2 or more cups of Green Tea every day?
Yes
No |
44. Do you take a Fish Oil or Omega-3 Supplement on a regular basis (2 or more times per week)?
Yes
No |
45. Do you take a Vitamin D supplement (such as Vitamin D-3) on a regular basis?
Yes
No |
46. Do you take Sleeping Medicines, Prescription Pain Medicines or Narcotics on a regular basis?
Yes
No |
47. Have you moved to a new House or Apartment within the past 12 months?
Yes
No |
48. Have you gone through a divorce in the last 12 months or are you currently involved in a
divorce action?
a. Gone through a Divorce:
Yes
No
b. Currently involved in a Divorce:
Yes
No |
49. Have you had a death of a child, parent or very close relative in the past 12 months?
Yes
No |
50. Have you been involved in a home foreclosure, bankruptcy, or stressful lawsuit in the past 12 months?
a. Home foreclosure:
Yes
No
b. Bankruptcy:
Yes
No
c. Stressful lawsuit:
Yes
No |
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