Full Name
*
First Name
Last Name
Age
years
Gender
Male
Female
Do you follow a specific eating style or diet?
Yes
No
If so, please state what and since when?
What is a typical breakfast?
Do you eat lots of greens on a daily basis?
Never
Rarely
Occasionally
Always
In the past 3 years how many courses of antibiotics have you been on?
On average, how many fruit juices or fizzy drinks do you have a week?
How many caffeinated beverages do you consume a day?
Do you have one within the first hour of waking up?
Yes
No
How many teaspoons of sugar do you have in your tea or coffee?
How many times a week do consume alcohol?
What do you snack on during the day?
How often do you make eating decisions you regret?
Never
Rarely
Sometimes
Often
Very often
Around what time in the evening do you stop eating?
Do you take any supplements?
Yes
No
If so, please state which ones
On average, how much water do you drink a day?
SLEEP
On average, how many hours of sleep do you get a night?
How long does it usually take you to fall asleep once in bed?
If you have any diagnosed health problems list the condition(s).
If you have any preexisting condition? injury or illness
Do you have issues staying asleep through the night?
Never
Rarely
Sometimes
Often
Very often
Does this vary much on the weekend?
Yes
No
What time do you usually go to sleep?
How many nights a week would you say you have a problem with your sleep?
How would you rate your sleep quality?
Very poor
Poor
Average
Good
Very Good
How would you rate your energy levels when you wake up in the mornings?
Very poor
Poor
Average
Good
Very good
How would you rate your energy levels throughout the day?
Very poor
Poor
Average
Good
Very good
How many times do you snooze your alarm in the mornings?
0
1
2
3+
Do you use any electronic devices whilst in bed? Phone, laptop etc
Never
Rarely
Sometimes
Always
Stress
On a scale of 1-10 what would you rate your general level of anxiety/stress?
How stressful do you consider your job?
Not stressful
Slightly stressful
Stressful
Very stressful
Are there any other things that cause you notable stress?
Are there any things you believe you use to distract yourself from, or to conceal your anxiety and stress?
Yes
No
If so, through which means do you tend to do this?
Do you watch, listen to, or read the news on a daily basis?
Yes
No
How much time on average, do you spend scrolling on social media?
How often do you feel negative emotions arise out of nowhere?
Never
Rarely
Sometimes
Often
Very often
If there are any, please list any habits you've been wanting to cut out?
If there are any, please list any habits or lifestyle changes you've been wanting to bring in?
General Health
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
How many times a week do you exercise/move with some intensity?
Which kind(s) of exercise/movement do you do and for how long?
Are you a current cigarette smoker?
Yes
No
If so, how many do you smoke a day?
If you are on any medications?
How much time would you be willing to allocate yourself for a morning routine?
How much time would you be willing to allocate yourself for an evening routine?
Please rate your readiness for change
1
2
3
4
5
6
7
8
9
10
Do you have a positive self image
not at all
somewhat
good
Rock Star
If you could have anything you want what would that be?
Submit
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