Future Toilet
æĨæŦčĒ/EN
Health Questionnaire
Age Range
Select your age range
18-24 years
25-34 years
35-44 years
45-54 years
55+ years
Gender
Male
Female
Other
Health
đ Good
đ Fair
âšī¸ Poor
Appetite
đ Good
đ Fair
âšī¸ Poor
Sleep
đ Good
đ Fair
âšī¸ Poor
Stress
đ Good
đ Fair
âšī¸ Poor
Illnesses you have had
High blood pressure
Diabetes
Heart disease
Apoplexy
Cancer
Liver disease
Gastrointestinal disease
Arthritis
Allergies
Special blood
Gastric purging
Thyroid disease
Osteoporosis
Cataracts
Oral cataracts
Dysphagia
Sleep apnea
Rheumatism
Dementia
Start Diagnosis
If you have any questions, please ask a member of staff.
