Basic Information
Duration
Health History
Alcohol
Help
Area
Full Name
Age
Gender
Number
Email
Describe your condition
Less than a week
Less than
a week
1–3 months
More than 3 months
More than
3 months
Any medical conditions?
Diabetes
High blood pressure
Heart disease
Obesity
Depression or anxiety
Do you consume alcohol?
Do you consume
alcohol?
Yes
No
Occasionally
Are you open to lifestyle change or medical help?
Not sure
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