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About
How It Works
Health Questionnaire
Contact
Custom Helth Plan Form
Personal Information
Full Name
Email
Your Age
Height
Your Gender
Weight
Occupation
Working Hours
Day Shifts
Night Shifts
Rotating Shifts
Family Status
Single
Married
Children
Select Your Primary Goals
Select Your Primary Goals
Weight Loss
Improved Sleep
Increased Energy
Stress Reduction
Better Gut Health
Improved Mental Clarity
Other
Specify Your Primary Goals
Current Lifetstlye and Habits
Sleep Patterns
Average Sleep Hours Per Night
Do you struggle to fall asleep, stay asleep, or wake up feeling rested?
Yes
No
Sleep Consistency
Physical Activity
How often do you exercise?
Never
1-2 times/week
3-4 times/week
5+ times/week
Type of Exercise
Select Exercise
Cardio
Strength Training
Yoga
walking
etc
Do you experience physical pain or limitations that affect exercise?
Yes
No
Diet and Nutrition
Do you follow a specific diet?
How often do you cook at home?
Rarely
Sometimes
Often
Do you consume Sugary Drinks?
Rarely
Sometimes
Often
How many meals/snacks do you eat per day?
Do you consume Processed Foods ?
Rarely
Sometimes
Often
Do you consume Alcohol ?
Rarely
Sometimes
Often
Stress Levels
How would you rate your daily stress?
Low
Moderate
High
How do you usually cope with stress?
What are your main stressors?
Work
Family
Finances
Other
Please Specify What are your main stressors
Water Intake
How many glasses of water do you drink daily?
Smoking/Vaping
Do you smoke or vape?
Yes
No
Do you smoke or vape Frequency ?
Health Metrics
Health Metrics
Do you have any of the following conditions?
Diabetes
Hypertension
High Cholesterol
Sleep Disorders (e.g., insomnia, sleep apnea)
Mental Health Challenges (e.g.. anxiety, depression)
Other
Please specify
supplements Intake
Do you take any regular medications or supplements?
Energy Levels
How would you rate your energy throughout the day?
Low
Moderate
High
When do you feel the most tired?
Morning
Afternoon
Evening
Digestion
Do you experience bloating, constipation, or other digestive issues?
Daily Routine
Morning Routine
What time do you wake up?
Do you have any consistent habits?
Work Routine
Describe your typical workday.
Do you eat during work?
Yes
No
How many breaks do you take during work hours?
What do you typically eat at work?
Evening Routine
What time do you finish work?
Do you engage in any wind-down activities before bed?
Weekend Routine
Are weekends structured differently?
Yes
No
How do you typically spend weekends?
Pain Points and Barriers
Awareness
Do you feel aware of the impact your habits have on your health?
Yes
No
What health challenges do you struggle with most?
Desire
How motivated are you to improve your health?
What would make it easier for you to make changes?
Knowledge
Do you feel you have enough knowledge about health and wellness?
Yes
No
What areas do you need more guidance on?
Ability
What prevents you from making healthier choices?
Do you feel confident in your ability to stick to a health plan?
Reinforcements
Have you tried improving your health before?
Yes
No
What helped or hindered your success?
What support systems do you have in place
Preferences and Goals
Preferred Approach To Health
Do you prefer small, gradual changes or big, transformative changes?
Food Preferences
Are there foods you love or dislike?
Do you have any dietary restrictions or allergies?
Budget For Health
How much are you willing to invest in your health monthly?
Time commitment
How much time can you realistically dedicate to health-related activities each day?
Optional Open-Ended Questions
What does "good health" mean to you?
If you could change one thing about your health or lifestyle, what would it be?
What's your biggest challenge in achieving your health goals?
Complete My Health Assessment
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