TrueMed – Employee Health Survey

1 Personal Information

Last Name*

Last name is required.

First Name*

First name is required.

Contact Number*

Contact number is required.

Company Name*

Company name is required.

2 Prior Conditions

Do you have any prior or existing medical conditions?*

e.g. hypertension, diabetes, heart disease

Please select Yes or No.

3 Maintenance Medicines

Does your doctor prescribe you maintenance medicines?*

Medicines you take regularly every day

Please select Yes or No.

4 Other Medicines

Do you currently take non-maintenance medicines?*

e.g. antibiotics, pain relievers, vitamins, supplements

Please select Yes or No.

What medicines are you currently taking?

5 Consent

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