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QURE1 - Comprehensive Health Assessment

www.qure1.com | hello@qure1.com | 01169266273, 9048773444

Section A: Patient Demographics
Section B: Medical & Surgical History

Chronic Diseases (Tick all that apply)

Surgical History

Allergies

Ongoing Medications

Name Dose Duration Indication
Section C: Family History
Condition Relatives Affected Age of Onset
Hypertension
Heart Disease
Diabetes
Stroke
Obesity
Cancer (Specify)
Mental Illness
Section D: Anthropometry & Clinical Vitals
Note: A healthy BMI (Body Mass Index) for adults typically falls between 18.5 and 24.9.
Note: A healthy WHR is 0.9 or less in males, and 0.85 or less in females.
Section E: Lifestyle Risk Profile

1. Dietary Assessment

Food Group Frequency (Days/Week) Portion Size Notes
Fruits
Vegetables
Whole Grains
Milk / Dairy
Fried / Processed
Sugary Drinks
Red Meat

2. Other Lifestyle Factors

3. Physical Activity

4. Sleep Pattern

5. Mental and Emotional Health

Section F: Reproductive Health (Females Only)
Section G: Validated Risk Scores
1. QRISK 3 CALCULATOR
2. WHO cardiovascular disease risk non-laboratory-based charts
WHO ISH Risk Chart
a. <5%
b. 5% to <10%
c. 10% to <20%
d. 20% to <30%
e. ≥30%
WHO Management Chart
3. ADA Prediabetes Risk Score

Total ADA Score: --

Management:
  • ≥5: High risk → Screen for HbA1c, initiate lifestyle program
4. PHQ-9 Depression Scale
ItemNot at all (0)Several Days (1)More than half (2)Nearly every day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling asleep or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure
7. Trouble concentrating on things
8. Moving or speaking slowly / fidgety behavior
9. Thoughts of being better off dead / self-harm

Total PHQ-9 Score: --

Total Score (0–27): Interpretation & Management:
  • 0–4: Minimal → Reassure
  • 5–9: Mild → Lifestyle changes
  • 10–14: Moderate → Psych referral
  • 15–19: Mod-Severe → Add CBT or therapy
  • 20–27: Severe → Psychiatric intervention
5. GAD-7: Generalized Anxiety Disorder Scale
ItemNot at all (0)Several Days (1)More than half (2)Nearly every day (3)
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

Total GAD-7 Score: -- | Risk Level: --

Total Score (0–21): Management:
  • 0–4: Minimal → Monitor
  • 5–9: Mild → Stress coaching
  • 10–14: Moderate → Psych consult
  • 15–21: Severe → Therapy + meds
6. Perceived Stress Scale (PSS-10)
QuestionNever (0)Almost Never (1)Sometimes (2)Fairly Often (3)Very Often (4)
1. been upset because of something that happened unexpectedly?
2. felt that you were unable to control the important things in your life?
3. felt nervous and "stressed"?
4. felt confident about your ability to handle your personal problems? (+)
5. felt that things were going your way? (+)
6. found that you could not cope with all the things that you had to do?
7. been able to control irritations in your life? (+)
8. felt that you were on top of things? (+)
9. been angered because of things that were outside of your control?
10. felt difficulties were piling up so high that you could not overcome them?

Total PSS Score: --

Total (0–40): Interpretation:
  • 0–13: Low stress
  • 14–26: Moderate → Stress control
  • 27–40: High → Specialist referral
Section H: Investigations Ordered
Section I: Smart AI Assessment

1. AI-Based Diagnosis

2. AI-Based SMART Goals

Section J: SMART Goals by QURE1 Buddy Team
Section K: Consent

I consent to participate in a structured lifestyle and chronic disease assessment by Canserv Healthcare. I understand my data will be confidential and used for care delivery.

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