Email
example@example.com
Customer Name
First Name
Last Name
Estimated avg exercise in min per day
*
Age
*
Gender at Birth
*
Male
Female
Weight
*
Height
*
Current Physical Activity
Please Select
Sedentary
Low Active
Active
Very Active
Back
Next
How many hours sleep do you get on average per night?
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
How well do you sleep?
Please Select
My sleep is good
Getting to sleep is difficult
I wake up in the middle of the night
I wake up feeling tired still
How many nights over the past week have you had broken sleep?
Please Select
0
1
2
3
4
5
Do you struggle to get out of bed in the morning?
Yes
No
Do you have young children that regularly wake you up in the middle of the night?
Yes
No
Sleep Result
Rate your energy levels over the past week out of 5 (5 = significantly agree I have a lot of energy & 1 = significantly disagree I have very low energy)
Please Select
1
2
3
4
5
Rate your motivation levels over the past week out of 5 (5 = significantly agree I have been highly motivated this week & 1 = significantly disagree I have been unmotivated this week)
Please Select
1
2
3
4
5
Mental Health Result
How many shots of caffinated coffee / tea do you have per day (note large coffees can have 2-3 shots per cup)?
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
How many cups of non caffinated liquid do you drink i.e. tea / milk / juice / water do you have per day?
*
Please Select
Less than 1000ml
Less than 2000ml
Less than 3000ml
Less than 4000ml
Less than 5000ml
hydration_uid_9_number
Hydration Result
How many weeks ago was the last time you did something Noval (i.e. something you have not done in a long time or never done; or is unusual or is out of your comfort zone).
Please Select
1
2
3
4
5+
Novelty Result
How many hours a week do you socialise in a non work setting with people i.e. friends or family or work collegues?
Please Select
0-6
7-9
10+
result_social_uid_11
Do you want to spend more time with family & friends?
Yes
No
Social Result
How many days in the past week did you exercise?
Please Select
0
1
2
3
4
5
6
7
When you exercise how many times a week do you reach maximum heart rate i.e. high intensity / heavy breathing?
Please Select
0
1
2 or more times
When you exercise, how many minutes do you exercise for on average?
Please Select
0
15
30
45
60
75
90 +
Exercise result
Do you have any injuries at the moment or a physical impairment that is a recent problem in your life?
*
Yes
No
Does this injury cause you pain every day?
*
Yes
No
Rate this pain out of 5? (5 = I am in a signifcant amount of pain & 0 = no pain)
*
Please Select
0
1
2
3
4
5
Do you have any recent physical issues (e.g., gut, skin, headaches, fatigue, or other) that have recently become a problem in your life?
Yes
No
Does this physical issue or injury stop you from doing anything (i.e. work / exerercise / sleep)?
*
Yes
No
Physical_health Result
How would you rate your physical health generally out of 5 (5 = significantly agree I have excellent physical health & 1 = significantly disagree I have very poor physical health)
Please Select
1
2
3
4
5
Are you emotionally stressed and worried about this injury or physical issue?
Yes
No
In the past two weeks, how often have you felt down?
Please Select
Not at all
Several Days
More than half the days
Nearly every day
Is there a Hobby or Goal or Ambition you wished you had more time to do more of?
Yes
No
If so, how many more times per week?
Please Select
0
1
2
3
4
5
6
7+
Hobby Result
Submit
Should be Empty: