Metabolic Health Quiz
Name
*
First name
Email
*
example@example.com
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Age
What is your age?
*
<30
31-40
41-50
51-60
>60
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Eating Habits
How many meals do you typically eat in a day?
1-2
3-4
5 or more
How many serves of fruit do you eat in a day?
0
1
2 or more
How many serves of vegetables do you eat in a day?
0
1-2
3-4
5 or more
How often do you consume sugary beverages (e.g. soft drink, fruit juice or energy drinks)?
Rarely or never
Once a week
Several times a week
Daily
How often do you eat out or order takeaway?
Rarely or never
Once a week
Several times a week
Daily
How often do you drink alcohol?
Rarely or never
Once a week
Several times a week
Daily
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Physical Activity, Sleep and Stress
How often do you engage in at least 30 minutes of moderate intensity cardiovascular training (e.g. walking, cycling, dancing) in a week?
Rarely or never
1-2 times
3-4 times
5 or more times
How often do you engage in strength training (e.g. weights, pilates, bodyweight exercises) in a week?
Rarely or never
Once
2 or more times
How many hours of sleep do you typically get?
Less than 5
5-6
7-9
More than 9
How would you rate your current stress levels?
Low
Moderate
High
Very high
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Clinical Data
What is your waist circumference (measured in line with your belly button)?
Less than 80 cm (females) or 94 cm (males)
80-88 cm (females) or 94-102 cm (males)
More than 88 cm (females) or 102 cm (males)
Are you on any medications for blood pressure, cholesterol or diabetes?
Yes
No
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Clinical Data Continued
The remaining four questions ask about your blood pressure and results of blood tests (triglycerides, HDL-cholesterol and fasting glucose).
I have these values and would like to input them
I'd like to skip these questions
At your most recent measure, was your blood pressure:
Less than 130/85 mm/Hg
Greater than or equal to 130/85 mm/Hg
One number was higher than the range listed, but not both (e.g. 140/83 mm/Hg)
On your most recent blood test, what was your triglyceride level?
Less than 1.7 mmol/L
Greater than or equal to 1.7 mmol/L
On your most recent blood test, what was your HDL-cholesterol (good cholesterol) level?
Less than 1.0 mmol/l (males) or less than 1.3 mmol/L (females)
Greater than or equal to 1.0 mmol/L (males) or 1.3 mmol/L (females)
On your most recent blood test, what was your fasting glucose (sugar) level?
Less than 5.5 mmol/L
Greater than or equal to 5.5 mmol/L
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Health Goals
What is your primary health goal?
Weight loss
Improve energy levels
Manage a health concern
Improve metabolic health
Other
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