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Male Health Survey
*
1.
Please take a few moments to do our Male Health Survey. When your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?
(Required.)
I agree
I do not agree
*
2.
What is your Name and Surname?
(Required.)
3.
If you are not a client, please supply your email address below?
*
4.
Which Skin Renewal branch is your home branch?
(Required.)
Brooklyn
Bedfordview
Claremont
Cape Quarter
Constantia
Fourways
Hillcrest
Irene
Illovo
Morningside
Parkhurst
Somerset West
Stellenbosch
Umhlanga
West Rand
Willowbridge
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5.
What is your Age?
(Required.)
Under 35
35-50
*
6.
Have you had your blood pressure checked in the last 6 months?
(Required.)
Yes
No
*
7.
Have you had your cholesterol checked in the last year?
(Required.)
Yes
No
*
8.
Have you had your blood sugar checked in the last year?
(Required.)
Yes
No
*
9.
Have you had your prostate checked in the last year?
(Required.)
Yes
No
*
10.
Do you deliberately limit the amount of fats in your diet?
(Required.)
Yes
Mostly
No
*
11.
Have you spoken to your doctor about your risk for bowel cancer?
(Required.)
Yes
No
*
12.
In general, are you happy and not too stressed?
(Required.)
Yes
Mostly
No
*
13.
Are you a non-smoker?
(Required.)
Yes
No
*
14.
Do you have a partner, close friend or relative who is there for you in tough times?
(Required.)
Yes
No
*
15.
Do you have at least 3 alcohol free days per week?
(Required.)
Yes
No
*
16.
Do you eat 5 or more servings of fruit and vegetables per day?
(Required.)
Yes
No
*
17.
Have you had your skin checked in the last year?
(Required.)
Yes
No
*
18.
Have you ever been for a general men’s health check up when you are not sick?
(Required.)
Yes
No
*
19.
Have either of your parents or siblings been diagnosed with type 2 diabetes?
(Required.)
Yes
No
*
20.
Do you regularly check your testicles for lumps or other abnormalities?
(Required.)
Yes
No
*
21.
Do you feel ok about getting help when you feel down?
(Required.)
Yes
No
*
22.
Have you had a flu vaccination in the last year?
(Required.)
Yes
No
*
23.
Do you take a Men’s multi-vitamin daily?
(Required.)
Yes
No
*
24.
Have you tested your hormone levels in the last year?
(Required.)
Yes
No
* This survey is an adaptation of Foundation 49’s One Minute Men’s Health Check. This survey is not a diagnosis. It is recommended that all men visit a GP on a yearly basis.
