Form - DataWell.Me

General Questions

Gender(Required)

Male (inc. trans men)	Woman (inc. trans women)	Non-binary

Date of Birth(Required)

Height(Required)

Please enter a number from 60 to 300.

In Centimeters

Weight(Required)

Please enter a number from 30 to 400.

In Kg

Is this the gender you were assigned at birth? *(Required)

yes	no

Sexual Orientations(Required)

Lesbian / Gay	Straight / Heterosexual	Bisexual

Are you allergic to something?(Required)

Yes	No

Country of Origin(Required)

Country of Birth(Required)

Nationality(Required)

Language Spoken At Home(Required)

COPD

Cough

Phlegm

Chest tightness

Breathlessness

Activities

Energy

Cough

	most days a week	several days a week	a few days a month	only with chest infections	not at all
Over the past 3 months, I have coughed:
Over the past 3 months, I have brought up phlegm (sputum):
Over the past 3 months, I have had shortness of breath:
Over the past 3 months, I have had attacks of wheezing:

Dementia

	Yes	No
Do you regularly take steps to look after your mental wellbeing?
Have you, or friends or family, ever had concerns about your hearing?

looking after mental wellbeing could include taking time out for hobbies and activities you enjoy or talking with friends and family. Anything that helps you feel happier, healthier and more relaxed

	Needs Work	Ok	Good	Excellent
How would you rate your diet?

challenging your brian can include challenging work, reading, playing games, doing puzzles, learning a language, or playing an instrument

	Used to but I've quit	No	Occasionally	Everyday
Do you smoke cigarettes

	Never	Occasionally	Most Weeks	Every Week
Per week how often do you do : Two and a half hours of moderate physical activity (e.g. 30 mins on 5 days) OR An hour and a quarter of vigorous physical activity (e.g. 25 mins on 3 days)?
How often do you drink more than 14 units of alcohol in a week?

Please see the list below for some examples of the average alcoholic content of some common drinks) Bottle (75cl) of wine – 10 units Small (125ml) glass of wine – 1.5 units Standard (175ml) glass of wine – 2.1 units Large (250ml) glass of wine – 3 units Pint of weaker (3.6%) beer – 2 units Pint of stronger (5.2%) beer – 3 units Bottle (330ml) of beer – 1.7 units Can (440ml) of beer – 2 units Alcopop bottle (275ml) – 1.5 units Small (25ml) shot of spirits – 1 unit Large (35ml) shot of spirits – 1.4 units

	1-3 Hours	4-6 Hours	7 or more
How many hours of quality sleep do you get a night?

	Yes	No
Have any first-degree relatives (parents, siblings, children) been diagnosed with heart disease before the age of 60?
Have you noticed any unexplained fatigue or weakness lately?
Do you have any history of anxiety or depression?
Do you experience shortness of breath?
Do you experience chest pain or discomfort?

Heart Disease

	Low	Moderate	High
How would you describe your stress levels on a daily basis?

	Rarely	Occasionanlly	Regularly
How often do you consume foods high in saturated fats? (e.g., fried foods, processed meats)

malaria

	Yes	No	Usure
Have you noticed any unexplained fatigue or weakness lately?

Pneumonia

	Yes	No
Are you employed in an occupation with a higher risk of respiratory exposure? (e.g., healthcare, agriculture) (Yes/No)(Required)

	Always	Frequently	Occasionally	Rarely	Never
How often do you practice good hand hygiene, including washing hands with soap and water or using hand sanitizer (Daily) ?(Required)

Stroke

When you raise both arms, is one arm weaker than the other?

When you smile, Is one side of the face droping?

When you repeat a simple sentence, is speech slurred or difficult to understand?

headaches

Yes, I am experiencing a severe headache with no known cause.	Yes, I have severe headaches, but they have a known cause.	No, I am not experiencing any headaches at the moment.	I occasionally experience headaches, but they are not severe.

Are you having sudden trouble seeing in one or both eyes? e.g. double vision

Yes, I am having sudden trouble seeing in one eye.	Yes, I am having sudden trouble seeing in both eyes.	I am experiencing intermittent visual problems.	No, I am not having any sudden trouble with my vision.	I have a pre-existing vision problem but no new or sudden changes.

Are you feeling dizzy or experiencing a sudden loss of balance or coordination?

Yes, I am feeling dizzy.	Yes, I am experiencing a sudden loss of balance.	Yes, I am experiencing issues with coordination.	I am experiencing both dizziness and loss of balance/coordination.	No, I am not experiencing any dizziness, loss of balance, or coordination issues.

balance

Yes, I am having trouble walking.	Yes, I am having trouble maintaining my balance.	I am having both trouble walking and maintaining my balance.	No, I am not having trouble walking or maintaining my balance.	I sometimes have trouble with walking or balance, but it is not a new issue.

Have you experienced a sudden loss of consciousness or fainting?

Yes, I have experienced a sudden loss of consciousness recently.	Yes, I have fainted recently.	I have experienced this in the past, but not recently.	No, I have never experienced a sudden loss of consciousness or fainting.

Substances

Have you noticed unexplained weight loss recently?

Yes, I have noticed significant unexplained weight loss recently.	No, I have not noticed any unexplained weight loss.	I have lost some weight, but I believe it's explainable.

Are you on any regular medication?

Yes	No

Are you…

A current Smoker?	An Ex-Smoker?	Never smoke

Have you ever consumed any substances for non-medical reasons?

No	Yes

Heart disease

no	yes

Stroke

No	Yes

copd

no	yes

dementia

No	Yes

trachea

No	Yes

Phone

This field is for validation purposes and should be left unchanged.

	Never	Occasionally	Most Days	Everyday
How often do you meet or speak to friends, colleagues, or family?
How often do you do activities that challenge your brain?
How often do you drink alchol

	Yes	No
history of high blood pressure?
high cholesterol?
sleep apnea?
diabetes?

	Rarely	Occasionally	Frequently	Almost Always	Strongly agree
How often do you experience fever, chills, or sweats?
Do you often experience headaches or migraines?

How It Works

About

White Paper

Contact

Main Questionnaire

General Questions

COPD

Dementia

Heart Disease

malaria

Pneumonia

Stroke

Substances