Naluri X PMCare

Naluri X PMCare

YOUR DETAILS

FULL NAME AS PER IC

IC NUMBER (NEW)

MOBILE NUMBER

YOUR HEALTH INFORMATION

Please answer all of these questions.

Your Well Being

1 - Did not apply to me at all

2 - Applied to me a considerable degree or a goof part of time

3 - Apply to me to some degree, or some of the time

4 - Applied to me very much or most of the time

Well Being: Based on rating number above, kindly tick ONE where applicable.

	1	2	3	4
I FOUND IT HARD TO WIND DOWN
I WAS AWARE OF DRYNESS OF MY MOUTH
I COULDN'T SEEM TO EXPERIENCE ANY POSITIVE FEELING AT ALL
I EXPERIENCE BREATHING DIFFICULTY (e.g EXCESSIVELY RAPID BREATHING, BREATHLESSNESS IN THE ABSENCE OF PHYSICAL EXERTION)
I FOUND IT DIFFICULT TO WORK UP THE INITIATIVE TO DO THINGS
I TENDED TO OVER-REACT TO SITUATIONS
I EXPERIENCED TREMBLING (e.g IN THE HANDS)
I FELT THAT I WAS USING A LOT OF NERVOUS ENERGY
I WAS WORRIED ABOUT SITUATIONS IN WHICH I MIGHT PANIC AND MAKE A FOOL OF MYSELF
I FELT THAT I HAD NOTHING TO LOOK FORWARD TO
I FOUND MYSELF GETTING AGITATED
I FOUND IT DIFFICULT TO RELAX
I FELT DOWN-HEARTED AND BLUE
I WAS INTOLERANT OF ANYTHING THAT KEPT ME FROM GETTING ON WITH WHAT I WAS DOING
I FELT I WAS CLOSE TO PANIC
I WAS UNABLE TO BECOME ENTHUSIASTIC ABOUT ANYTHING
I FELT I WASN'T WORTH MUCH AS PERSON
I FELT THAT I WAS RATHER TOUCHY
I WAS AWARE OF THE TACTION OF MY HEART IN THE ABSENCE OF PHYSICAL EXERTION (e.g SENSE OF HEART INCREASE, HEART MISSING A BEAT)
I FELT SCARE WITHOUT ANY GOOD REASON
I FELT THAT LIFE WAS MEANINGLESS

Your Medical History

Medical History: Kindly tick ONE where applicable.

Your Activity Level

Activity Level: Kindly tick ONE where applicable.

Sedentary

Lightly Active

Moderately Active

Intense Weight Training Program / sports 4-5 days per week

Very Active

Extra Active

Tobacco & Alcohol Consumption

Tobacco Consumption: Are you regularly smoking cigarettes or any form of tobacco?

Yes

Alcohol Consumption: Do you consume alcohol?

Yes

Current Health Condition

Current Health Condition: Kindly tick ONE where applicable.

	Yes	No
I am currently pregnant / may be pregnant
Persistent coughing, breathlessness, coughing blood
Chest pain, palpitations
Indigestion, nausea, heartburn
Diarrhoea, constipation, blood in stool, black color stool
Loss of weight, loss of appetite
Urinary problems : Pain on passing urine, increase frequency of urine, abnormal color urine, unable to hold urine, poor flow of urine
Skin problems: new moles, rash, psoriasis, acne
Weakness of limbs
Headache, dizziness, fainting spells
Mood changes, insomnia, anxiety, stress
Eyes:blurred vision, doublevision, field of vision
Ears:reduced hearing, ringing sounds
Abnormal lumps noticed
Musculoskeletal:muscle pain, joint pain, back pain, neck pain
Menstrual:irregular, heavy, spotting, vaginal discharge
None

Your Weight (KG)

Your Height (CM)

Waist Circumference (CM)

Are you currently taking any medication(s)?

Yes

If yes, please write down medication(s) that you are currently taking.

Have you had any surgeries in the past)

Yes

Family Medical History

(1st degree only : grandparents, parents, brothers and sisters, children)

Are you taking any herbal or pharmaceutical supplements regularly?

Yes

Have you had more than 2 sexual partners in the past 6 months?

Yes

Do you have any history of dialysis/blood transfusions?

Yes

Company Name

Marriage Status

Single

Married

Widowed

Divorced

Number of Children

Highest Education Achieved

Home State (e.g Kuala Lumpur, Selangor)

Postcode

	Yes	No
Do you have any allergy?
Nuts
Eggs
Gluten (Wheat, grains)
Soy
Milk
Dust
Seafood
Fur

	Yes	No
Have you been diagnosed with any medical illness(es)
Stroke
Diabetes
Hypertension
High Cholesterol
Cancer
Mental Health Problems
Asthma
Heart Disease
Arthritis
Blood Clots
Glaucoma

	Yes	No
None
Heart Disease
Stroke
Diabetes
Hypertension
High Cholesterol
Cancers
Mental Health Problems
Asthma
Arthritis
Blood Clots
Glaucoma
Kidney Failure

NALURI X PMCARE