Expert Health & Wellness Services | Ministry Wellness Center

Where Healing Begins and Wellness Thrives

Offering Health Solutions to Embrace a Healthier Lifestyle

Comprehensive Health Screening Questionnaire

Help us personalize your care! This brief survey gathers key details for comprehensive health screenings, focusing on chronic disease management. Your input guides our approach to better meet your unique health needs. Thank you for taking a moment for your well-being.

Personal Information

First Name(Required)

Last Name(Required)

Date of Birth

Gender

Male

Female

Email(Required)

Phone Number(Required)

Medical History

Do you have any existing medical conditions? Please specify.

List any surgeries or significant medical procedures you have undergone.

Family Medical History

Are there any chronic diseases prevalent in your immediate family? Please provide details.

Lifestyle and Habits

Describe your typical daily diet.

How often do you engage in physical activity or exercise?

Please enter a number from 1 to 10.

Substance Use, Smoking, and Alcohol Consumption

Do you currently use tobacco, marijuana, or any other substances? If yes, please specify the type and frequency.

Do you currently smoke? If yes, how many cigarettes per day?

How often do you consume alcoholic beverages, and in what quantities?

Mental Health

Have you experienced high levels of stress or anxiety recently?

Do you have a history of mental health concerns?

Medication and Supplements

List any current medications or supplements you are taking.

Have you experienced any side effects from your medications?

Screening Tests

When was your last comprehensive health screening?

Have you had any specific tests related to chronic disease management? Please provide details.

Weight and BMI

What is your current weight and height?

Are you actively trying to manage your weight?

General Well-being

How would you rate your overall well-being on a scale of 1 to 10?

Is there anything else you would like to share about your health that may be relevant?

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MWC Membership We're Here For You

Embark on a proactive journey with Ministry Wellness Center (MWC) as we revolutionize the landscape of community health and wellness. Established with a commitment to enhance the well-being of our community, MWC has evolved into a comprehensive Wellness Center since 2017. We provide resources, education, consultation, support, and clinical services to ensure a healthy community.

Detailed health assessment
Comprehensive physical examination by a physician
Twice a month consultation as needed

Personalized health care
Assess to educational wellness sessions
Coordination of care with primary and specialty health care team

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Where Healing Begins and Wellness Thrives

MWC Membership We're Here For You

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