General Health Screening and Maintenance Checklist

[comment memo="General Health Screening and Maintenance Checklist"]

[comment memo="Personal Information"]
Full Name: [text name="full_name"]

Date of Birth: [date name="dob"]

Gender: [radio value="Male|Female|Other"]

[comment memo="Checklist Items"]
Please check the items below that apply to you:

[checkbox name="checklist_items" value="Annual physical examination|Blood pressure measurement|Cholesterol level screening|Blood glucose level screening|Body mass index (BMI) calculation|Immunizations up to date|Dental check-up|Eye examination|Hearing test|Screening for sexually transmitted infections|Skin cancer screening|Colon cancer screening|Mammogram (for females)|Pap smear (for females)|Prostate cancer screening (for males)|Bone density scan (for postmenopausal females)|Vitamin D level screening|Exercise for at least 30 minutes per day|Balanced diet|Adequate hydration|Adequate sleep|Stress management practices|Tobacco use cessation|Alcohol moderation|Regular medical check-ups|Screening for mental health issues"]

[comment memo="Additional Information"]
Please provide any additional information or questions you have:

[textarea name="additional_info" rows=3]

[comment memo="Submit"]
[link memo="Submit Form" url="https://www.example.com/submit" mark="submit-form"]

[mark name="submit-form"]
Thank you for completing the health screening and maintenance checklist. Your submission has been received.