Hawaii Health Risk Assessment

Personal Information

Full Name*

Please enter your full name.

Email Address*

Please enter a valid email address.

Phone Number

Date of Birth*

Please enter your date of birth.

Gender*

Please select your gender.

Address

Lifestyle and Habits

Do you smoke?*

Yes

No

Please select an option.

Do you consume alcohol?*

Yes

No

Please select an option.

Exercise Frequency*

Please select an option.

Dietary Preference*

Please select an option.

Average Sleep (hours/day)*

Please enter a valid number (0-24).

Medical History

Family History of Health Conditions?*

Yes

No

Please select an option.

Family History Conditions

Heart Disease

Diabetes

Cancer

Hypertension

Have you been diagnosed with any chronic diseases?*

Yes

No

Please select an option.

Chronic Diseases

Diabetes

Hypertension

Asthma

Symptoms and Current Health

Recent Symptoms?

Chest Pain or Discomfort

Shortness of Breath

Unexplained Weight Loss

Persistent Fatigue or Weakness

Overall Health Condition*

Please select an option.

Health Metrics (Optional)

Height (cm)

Weight (kg)

Blood Pressure (e.g., 120/80)

I consent to the analysis of my provided health information.

You must agree before submitting.