Personal Information (1/4) ^*

First Name ^*

Last Name ^*

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Personal Information (2/4) ^*

Email ^*

Phone Number ^*

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Personal Information (3/4) ^*

Sex at birth

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Personal Information (4/4) ^*

Age

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Personal History (1/3) ^*

Are you prone to any of the following?

Nut Allergy

Pollen Allergy

Sinus Allergy

None of the above

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Personal History (2/3) ^*

Do you currently have or in the past have a history of the following?

Hypertension (BP)

Diabetes

Heart Problem

None of the above

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Personal History (3/3) ^*

Are you allergic to any medications? If so please list them out:

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How do you rate your diet? ^*

Healthy – I prioritize balanced meals with nutritious foods.

Moderate – I try to eat well but have occasional indulgences.

Unhealthy – My diet consists mostly of processed or fast foods.

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How is your sleep schedule?  ^*

7 hours or more

6-7 hours

Less than 6 hours

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Do you currently smoke or use tobacco products? ^*

No, I do not smoke or use tobacco.

I have smoked in the past. Not anymore.

Occasionally – I smoke or use tobacco products occasionally.

Yes, regularly – I smoke or use tobacco products daily.

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Describe your alcohol consumption? ^*

Never drink – I have never consumed alcohol.

Used to drink – I previously consumed alcohol but no longer do.

Social drinker – I drink occasionally in social settings.

Heavy drinker – I consume alcohol frequently or in large amounts.

History of alcoholism

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Family History

Do any of your blood relatives have any other medical condition besides those already mentioned ? If yes, Please mention the condition:

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Recent History (2/11) ^*

Mark any of the following Gastrointestinal conditions you have been diagnosed with in the past:

GERD

Gastrointestinal Bleeding

IBS

Crohn's Disease

Stomach Ulcers

None of the above

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Recent History (3/11) ^*

Mark any of the following neurological conditions you have been diagnosed with in the past:

Multiple sclerosis

Seizures

Balance Disorder

Peripheral Neuropathy

Head Injury

Migraine

Headaches

None of the above

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Recent History (4/11) ^*

Mark any of the following Urological conditions you have been diagnosed with in the past:

Chronic Kidney Disease

Kidney Stones

Urinary Incontinence

Dialysis

None of the above

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Recent History (5/11) ^*

Mark any of the following ENT conditions you have been diagnosed with in the past:

Glaucoma

Vertigo

Hearing Problems

Nosebleeds

None of the above

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Recent History (6/11) ^*

Mark any of the following endocrinological conditions you have been diagnosed with in the past:

Hypothyrodism

Hyperthyroidism

Diabetes

None of the above

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If you have been diagnosed with diabetes in the past, please specify the type:

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Recent History (7/11) ^*

Mark any of the following psychological conditions you have been diagnosed with in the past:

Depression

Anxiety

ADD/ADHD

Schizophrenia

PTSD

Bipolar Disorder

None of the above

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If you have been diagnosed with any other psychological condition, please specify the type:

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Recent History (8/11) ^*

Mark any of the following Respiratory conditions you have been diagnosed with in the past:

Asthma

Bronchitis/Pneumonia

Emphysema/COPD

None of the above

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Recent History (9/11) ^*

Mark any of the following Musculoskeletal/Rheumatologic conditions you have been diagnosed with in the past:

Bursitis

Osteoarthritis

Osteoporosis

Fibromyalgia

Carpal Tunnel Syndrome

Rheumatoid Arthritis

Chronic Joint Pains

None of the above

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Recent History (10/11) ^*

Mention if you have been diagnosed with cancer in the past. If yes, specify the type:

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Recent History (11/11) ^*

Mention if any Other Medical Condition that you have been diagnosed with in the past:

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Medication History ^*

Are you currently on any medication? If yes, please list below:

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Do you feel pain in any area besides those already mentioned?

If yes, Please specify

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Activity History ^*

Do you exercise?

Negligible and/or only walking

Moderate

Intense, but only cardio

Intense, both cardio and resistance training

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Are there any specific health concerns you're hoping to get more information about during the scan?

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Disclaimer ^*

Your health and privacy matter to us. By signing this form, you acknowledge that you have read, understood, and agree to be bound by the terms outlined in the Privacy Policy and Terms & Conditions. With your electronic signature, you provide informed consent, ensuring a seamless and secure experience for your proactive health screening with EVO360.
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