Spectrum Health Screening Registration

Section 1: Basic Information

Name *

Date of birth * e.g. 18/05/1978

Gender *

Male

Female

Phone number *

Email address *

Section 2: Health Context

Do you have any existing medical conditions?

No known medical conditions

Diabetes / High blood sugar

Prediabetes / Borderline blood sugar

High blood pressure

High cholesterol

History of joint or muscle issues

History of anxiety or sleep difficulties

Other

Is anyone in your immediate family (spouse, parent, child) currently being treated for any of the following? *

Diabetes

Prediabetes

High cholesterol

High blood pressure

None of the above

Are you currently taking any medication? *

Yes

Not applicable

If yes, what kind of medication? (Tick all that apply)

Blood thinners or anti-coagulants

Diabetes medication (e.g. metformin, insulin, Ozempic, Wegovy)

Blood pressure medication

Cholesterol medication

Sleep or anxiety medication

Other

Are you currently taking any supplements? (Tick all that apply, or skip if none)

Vitamin C

Vitamin D

Fish oil / Omega-3

Calcium

Magnesium

Probiotic

Other

Section 3: How you're feeling

Anything bothering you lately? * (Tick all that apply, or tick "None" if you feel well)

Often tired or low energy

Thirst, frequent urination, or sugar crashes

Joint pain or muscle soreness

Frequent colds or feeling unwell

Poor sleep or trouble winding down

Often stressed or feeling overwhelmed

Weight loss or metabolic concerns

Men's health: low energy, libido, or prostate concerns

Women's health: fertility, hormonal, or menopause concerns

None, I feel well

Lifestyle habits (Optional, helps us advise you better. Tick all that apply)

Frequently consume sugary drinks

Sedentary lifestyle or rarely exercise

Irregular sleep schedule

Poor sleep quality

Often feel stressed

Smoker (cigarettes or vape)

Drink alcohol regularly

Other

I consent to Spectrum Health Sdn Bhd collecting and using my personal data (contact details, health information, and test results) for health screening, follow-up wellness advice, and marketing communications about Spectrum Health products, in accordance with Malaysia's Personal Data Protection Act 2010. *

Health Screening Registration

Thank you!