360° Holistic Wellness Assessment

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S. No
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Email* This field is required.
example@example.com
Email Verified
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3
How many times have you visited here before?** This field is required.
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Name* This field is required.
First Name
Middle Name
Last Name
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Date of Birth* This field is required.
Date
Day
Month
Year
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Gender* This field is required.
Male
Female
Other Binary
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What is your Height (cms)* This field is required.e.g 176, 182
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What is your weight (kgs)* This field is required.e.g; 50, 65, 75
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Your Blood Type* This field is required.
A+
A-
B+
B-
AB+
AB-
O+
O-
Bombay Blood Type
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Are you** This field is required.
Happily Married and have a good equation with your partner
Married and have lots of differences with your partner
Divorcee & Remarried once
Divorcee & Remarried Twice
Divorcee & Not Married
Single (Unmarried)
Widower & Remarried
Widower & Not Married
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Do you work in shifts?* This field is required.
Yes
No
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On average, how many total hours of sleep do you get in a 24-hour period (including nighttime sleep and naps)?* This field is required.
0
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Your Sleep Pattern? ( (24 hrs format))* This field is required.
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24
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Go to bed
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Wake up
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Go to bed
Wake up
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1
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How would you rate the overall quality of your sleep overall in past few months?* This field is required.
Very restful – I sleep through the night and wake up refreshed
Fairly good – Minor interruptions but feel mostly rested
Poor – Frequent awakenings and feel tired in the morning
Very poor – Struggle to fall/stay asleep and feel exhausted upon waking
16
How would you describe your general mood and emotional reactions?* This field is required.
Very irritable, anxious, or feeling of low daily
Often feel mentally unsettled
Mostly calm, sometimes emotionally low
Emotionally stable, positive mindset
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When faced with stress or challenges, how do you usually respond?* This field is required.
Feel helpless, can’t cope with problems
Often overwhelmed by stress
Can manage most situations
Bounce back quickly, stay composed
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How would you best describe your social relationships and support?* This field is required.
I feel emotionally connected, valued, and supported in my relationships. I regularly engage in meaningful, uplifting interactions
I have a few supportive relationships and connect socially when needed, though I sometimes crave deeper or more consistent interaction
I often feel disconnected or alone. Social interactions feel draining or infrequent, and I struggle to feel understood
I tend to avoid social contact, feel isolated most of the time, and find it hard to build or maintain meaningful relationships
19
Which of the following patterns best describes your recent behavior after spending time on social media?* This field is required.
I feel motivated or creatively inspired, and I’m able to return to my tasks with focus and energy
I find myself scrolling longer than intended, occasionally comparing myself to others, but I’m usually able to refocus
I feel mentally scattered, emotionally low, or dissatisfied with my own life after social media use
I frequently lose track of time, delay important tasks, and feel anxious or restless when not checking social media
20
What is your resting heart rate (Beats per minute - BPM)?* This field is required.Use a pulse oximeter to measure your resting heart rate early morning right after waking up, or after 5 minutes of complete rest.
mention the recorded number like 55,60,65,68 from the pulse oximeter above
21
Do you have any of these habits?* This field is required.
0
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20
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28
30
>30
Alcohol Drinking-Number of standard hard drinks/month (30ml ~ 1 Standard drink)
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Cigarette smoking/week
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Pan Masala & Tobacco/day
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Games (on Computer, Mobile, TV, etc.) hours/Week)
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Alcohol Drinking-Number of standard hard drinks/month (30ml ~ 1 Standard drink)
Cigarette smoking/week
Pan Masala & Tobacco/day
Games (on Computer, Mobile, TV, etc.) hours/Week)
0
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2
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4
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8
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28
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30
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>30
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0
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2
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4
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6
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8
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10
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20
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22
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28
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30
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>30
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0
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>30
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0
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8
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>30
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Type of Food You Take* This field is required.
Veg
Veg+Eggs
Vegan
Non-Veg
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Use this reference for calculating your daily Calorie intake
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What is your daily calories intake? * This field is required.(e.g: 1000,1200,1500,2000, etc. use the support given in the image above for calculation purposes)
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Out of the total calories mentioned above, how many calories is protein? * This field is required.(e.g.; 200,300,500, etc.)
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How many times do you eat in a day (24hrs)* This field is required.All big, medium, small meals (0.5 below is for those who eat once in two days)
0.5
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What’s the longest gap you typically have between any two meals, including overnight fasting?* This field is required.
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36
48
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What time do you eat your last meal of the day? (24 hrs format)* This field is required.
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What time do you eat? * This field is required.(24 hrs format)
None
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Early morning tea with biscuits, etc.
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Breakfast
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Morning Snack
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Brunch
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Lunch
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Linner or Dunch (Lunch + Dinner)
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Evening Snack
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Dinner
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Late Night Snack
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Any other meals
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Early morning tea with biscuits, etc.
Breakfast
Morning Snack
Brunch
Lunch
Linner or Dunch (Lunch + Dinner)
Evening Snack
Dinner
Late Night Snack
Any other meals
None
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7-8
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8-9
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None
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None
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7-8
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8-9
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9-10
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11-12
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12-13
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None
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6-7
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7-8
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9-10
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22-23
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23-24
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None
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7-8
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8-9
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9-10
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12-13
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None
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6-7
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8-9
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9-10
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10-11
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11-12
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12-13
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13-14
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20-21
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21-22
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22-23
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23-24
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None
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6-7
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7-8
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8-9
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9-10
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None
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None
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20-21
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22-23
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Row 8, Column 19
None
Row 9, Column 0
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22-23
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23-24
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30
What best describes your regular eating pattern?* This field is required.
Mostly balanced, home-cooked meals with regular timing
Irregular eating schedule, frequently skipping meals
Diet high in refined carbs, sugary snacks, and beverages
Frequent consumption of processed, packaged, or restaurant food
31
Your daily water intake (Liters)?* This field is required.
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
32
How is your physical activity?* This field is required.
No Exercises
Low Intensity Exercises (Yoga, Ti-Chi, Walking, Light Weights, etc.)
Medium Intensity (Cycling, Swimming, Jogging, Medium Weights, etc.)
High Intense Exercises (Running, Heavy Lifting, etc.)
Performance arts (like sports, dancing, martial arts, etc.)
I regularly run or train for long-distance events such as marathons or half-marathons
33
How many Days in a week you do exercises?* This field is required.
0
1
2
3
4
5
6
7
34
How many minutes do you exercise daily?* This field is required.
0
10
20
30
40
50
60
70
80
90
100
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
35
At what time of day do you usually perform the main part of your exercise? (24-hour format)* This field is required.
First half of 24hrs (After waking up till 12 hrs)
Second half of 24hrs (Between 12 - 18 hrs)
Third half of 24hrs (Between 18 - 24 hrs)
Fourth half of 24hrs (Between 24 - 6 hrs)
My daily routine integrates lots of exercise
None
36
Do you have any of these known situations that are causing you continuous stress?* This field is required.
Financial
Relationship
Job and Career
Social Media Pressure
Family and Friends Pressure
Bullied, Abused, Dumped
Disease or health issues
Living in an unsafe environment (e.g.: War zone, Terrorism, etc.)
Pollution
Blackmailed and or threatened
Death of a near or dear one
Divorce
Cognitive Stress or Studies causing stress
High work pressure
Any other stress not mentioned above
None
37
Do you have any known Genetic Issues?* This field is required.
Yes
No
38
How much is your screen time (phone/laptop/TV) in hours?* This field is required.
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
39
When was the last time you did a deworming cleanse or took antiparasitic treatment?* This field is required.
Within the last 6 months
6–12 months ago
Over a year ago
Never or can’t remember
40
Which statement best describes your current oral and gum health experience?* This field is required.
My teeth and gums feel clean, strong, and pain-free – no major concerns.
I occasionally feel sensitivity, dryness, or bad breath but it resolves on its own.
I often experience bleeding gums, persistent bad breath, or gum swelling.
My oral health feels neglected or worsening, but I haven’t prioritized treatment.
41
Do you have any of these health Conditions?* This field is required.
Low Blood Sugar
High Blood Sugar
Fluctuating Blood Sugar
High Blood Pressure
Low Blood Pressure
Fluctuating Blood Pressure
Rapid Heart Rate
Slow Heart Rate
Irregular Heart Rate
Salt Cravings
Sugar Cravings
Both Sugar and Salt Cravings
Frequent/loose Bowel Movements
Constipation
Swinging between Constipation and Frequent/Loose Bowel Movements
Insomnia, early waking
Excessive sleepiness
Broken or irregular sleep cycles
Increased Appetite
Decreased Appetite
Binge-eating or emotional eating patterns
High Cholesterol
Low or Normal Cholesterol
Hypothyroid
Hyperthyroid
Often feel lack of energy and tired
Do you have Health issues, which are not mentioned above
Have you noticed any health issues or decline post COVID
None
42
In case you want to know your biological age, heart age, risk of mental health disease?* This field is required.
Choose Yes, only if you know the numbers from your blood test for total cholesterol & HDL, HbA1c and your systolic & diastolic blood pressure numbers
Choose No, if don't know these numbers
43
What are your Total Cholesterol (mg/dL or mmol/L) numbers?* This field is required.
160–200mg/dL or 4.1 – 5.2 mmol/L
201–240mg/dL or 5.3 – 6.2 mmol/L
241–280mg/dL or 6.3 – 7.2 mmol/L
Above 280mg/dL or 7.2 mmol/L
44
What are your HDL Cholesterol (mg/dL or mmol/dL) numbers?* This field is required.
Under 40mg/dL or Under 1.03 mmol/L
40–49mg/dL or 1.04 – 1.27 mmol/L
50–59mg/dL or 1.28 – 1.53 mmol/L
Above 60mg/dL or 1.54 mmol/L
45
What is your latest HbA1c (Glycated Hemoglobin) result?* This field is required.
Under 5.4%
5.4–5.6%
5.7–6.4%
Above 6.5%
46
Your Systolic Blood Pressure (mm HG) numbers?* This field is required.
Under 120
120–129
130–139
140–159
Above 160
47
Your Diastolic Blood Pressure (mm HG) numbers?* This field is required.
Under 80
80-90
Above 90
48
Are you on any medication for the following diseases?* This field is required.
Blood Pressure
Blood Sugar
Cholesterol
None
49
Disclaimer and Acknowledgement* This field is required.I am confirming that the information I have provided is accurate and complete to the best of my knowledge. I understand that this wellness analysis is intended solely for general guidance and does not replace professional medical advice, diagnosis, or treatment from a licensed healthcare provider. Any recommendations or suggestions offered based on this analysis are to be followed only if they do not cause discomfort or adverse effects. If any discomfort arises, I agree to discontinue use immediately and consult a healthcare professional. The suggestions in this report are based on ancient healing traditions, modern clinical experience, and relevant research. While care has been taken to ensure that nothing harmful is recommended, I acknowledge that factors beyond our control, such as the presence of chemicals or pesticides in food, may affect individual responses. By proceeding, I acknowledge that I have read, understood, and accepted the above terms and disclaimers and the ones provided in the website (https://www.myhealthsmb.com/). I agree that the creators of this analysis shall not be held liable for any adverse outcomes resulting from the application of its recommendations.
I Accept
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