UltraLyfe Health Assessment

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
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Company Name* This field is required.Name of your employer Ex: Home Depot
4
Company Location* This field is required.Ex: Detroit, Michigan
5
On a scale of 1 to 10, how would you rate your overall energy levels consistently throughout the day? 10 being the highest and 1 being the lowest.
Low: I consistently struggle with low energy levels, feeling fatigued and lacking vitality.
Moderate: My energy levels fluctuate throughout the day, with occasional periods of tiredness.
High: I generally maintain good energy levels, experiencing few instances of fatigue.
Excellent: I consistently have high energy levels, feeling vibrant and energized throughout the day.
6
How would you describe your quality of sleep?* This field is required.
Poor: I have difficulty falling asleep and/or staying asleep, leading to restless and unsatisfying sleep.
Fair: My sleep quality is inconsistent, and I occasionally wake up feeling tired or unrested.
Good: I generally experience satisfactory sleep, with occasional disruptions or minor difficulties.
Excellent: I consistently enjoy restful and rejuvenating sleep, waking up feeling refreshed and energized.
7
How often do you experience symptoms of stress or anxiety?* This field is required.
Never: I rarely experience any symptoms of stress or anxiety.
Occasionally: I experience symptoms of stress or anxiety on rare occasions.
Sometimes: I experience symptoms of stress or anxiety periodically.
Often: I experience symptoms of stress or anxiety frequently.
Constantly: I experience symptoms of stress or anxiety on a daily basis.
8
Do you engage in regular physical activity or exercise?* This field is required.
Daily: I exercise or engage in physical activity every day. I prioritize regular exercise as part of my routine to maintain optimal health and well-being.
Several times a week: I exercise or engage in physical activity at least three to five times a week. I understand the importance of regular exercise and make a conscious effort to incorporate it into my schedule.
Occasionally: I engage in physical activity or exercise one to two times a week or whenever my schedule allows.
Rarely or never: I rarely or never engage in physical activity or exercise. I may have limitations or personal circumstances that prevent me from participating in regular exercise.
9
How would you rate your current diet in terms of nutrition and balance?* This field is required.
Poor: My diet lacks essential nutrients and is imbalanced, consisting mostly of unhealthy food choices.
Fair: My diet includes some nutritious foods, but there are also frequent indulgences in unhealthy options.
Good: I strive to maintain a balanced diet with a variety of nutritious foods, but there is room for improvement.
Excellent: I consistently follow a well-balanced diet that prioritizes nutrition and supports overall health.
10
Do you have any ongoing health concerns or chronic conditions?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Do you currently suffer from or have reoccurrences of any of the items listed below?* This field is required.Select all that apply.
Allergies
Anxiety
Stress
Headaches
Migraines
Back/Shoulder/Neck Pain
Aches & Pains Other Regions of Body
Congestion
Chronic Pain
Constipation
Digestive issues
Insomnia or Poor Sleep
Frequent Common Cold, Flu or Other Sicknesses
Feeling Tired or Low Energy Consistently
Lethargic
Injuries or Recurring Injuries
Feeling Burned Out
Menstral Cramps
Food Sensitivity
Frequent Mood Changes
Depression
Poor Diet
Unhappiness
Poor Mental State of Being
Overweight
Brain Fog
Trouble Concentrating
Chronic Fatigue
12
How well do you manage your work-life balance? * This field is required.
Poor: My work-life balance is heavily skewed toward work, leaving little time for personal life or self-care.
Fair: I struggle to find a healthy balance between work and personal life, often feeling overwhelmed or burnt out.
Good: I generally manage to maintain a reasonable work-life balance, although there may be occasional challenges
Excellent: I have a healthy work-life balance, effectively prioritizing both personal and professional commitments.
13
How often do you practice relaxation techniques or engage in stress-reducing activities?* This field is required.
Rarely: I seldom engage in relaxation techniques or activities to reduce stress.
Occasionally: I engage in relaxation techniques or stress-reducing activities on rare occasions.
Sometimes: I make an effort to practice relaxation techniques or engage in stress-reducing activities periodically.
Often: I regularly incorporate relaxation techniques or stress-reducing activities into my routine.
14
How satisfied are you with your current level of mental and emotional well-being?* This field is required.
Very Dissatisfied: I am consistently unhappy with my mental and emotional well-being.
Dissatisfied: I am generally unsatisfied with my mental and emotional well-being
Neutral: I have mixed feelings about my mental and emotional well-being.
Satisfied: I am generally satisfied with my mental and emotional well-being.
Very Satisfied: I am extremely content with my mental and emotional well-being.
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Are you interested in exploring natural and holistic approaches to support your overall health and well-being?* This field is required.
YESNO
Should be Empty: