Diet Clinic | Health Tips | Weight Loss

Anemia Risk Assesment

ANAEMIA RISK ASSESSMENT FORM

AGE

HAEMOGLOBIN

What kind of food you eat?

Are You Pregnant?

SMOKING

ACTIVITY LEVEL (aerobic exercise, at least 30 minutes per session)

BODY MASS INDEX

Have you noticed any bowel changes recently, particularly darker or more offensive smelling tools?

Do you suffer from gastrointestinal reflux disease or peptic ulcer disease?

Thank you for taking our survey.

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