Language
English (US)
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Health & Lifestyle Quiz
Name
*
First Name
Last Name
How healthy do you feel on a scale of 1-10?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How active are you on a daily basis?
*
Relatively active
Somewhat active
Very active
Not active
How often do you exercise
*
1-2 times a week
3-4 times a week
5-7 times a week
Never
Do you drink 2 litres of water on a daily basis?
*
Yes
No
What will you choose when you want to drink something other than water?
*
Green tea
Coffee (without sugar)
Black tea (or other kind of tea)
Coffee (with sugar)
Juice (non-carbonated drinks)
Carbonated drinks
What type of breakfast do you have most of the time?
*
Cereal / pastries
Cooked breakfast (full English)
Coffee / Tea
Toast
Protein shake / smoothie
Skip breakfast
Other
Do you get hungry or tired before lunch?
Yes
No
What do you normally have for lunch?
Fast food / meal deal
Packed lunch / sandwich
Fruit / yogurt
Coffee / Skip Lunch
Other
Do you pay attention to portion sizes during meals?
Yes
Sometimes
No
Do you snack late nights after dinner?
Yes
No
Sometimes
Do you know your daily protein target and why this is important?
*
Yes
No
What appeals to you the most when it comes to your physical health?
*
Lose Stubborn Body fat
Improve Overall Wellness
Improve My Energy
Build Lean Muscle Mass
A Mix of Things
On a scale of 1-10, how serious are you about your health and wellbeing?
Please Select
1
2
3
4
5
6
7
8
9
10
Would you say you are under weight, over weight or just right?
*
Under weight
Over weight
Just right
Other
Do you often have trouble falling or staying asleep?
*
Yes
No
Sometimes
In terms of your mental health-being how would you classify your mental state?
*
Reasonably happy & content
Very stressed
Very happy in all areas of my life
Somewhat unsatisfied with certain aspects of my life
What do you find brings you the most stress in your life?
*
Lack of Body Confidence
Never Enough Time
Unhealthy Lifestyle
Financial Pressures
In Summary, which of the following options would be your priority ?
*
Work on My Physical Results
Have More Time & Less Financial Stress
Be Part of a Positive Community
Adopt a Balanced Lifestyle
What's your age?
18-29
30-39
40-50
0ver 50
Would you like to know more on how we can help you with your goals?
*
Yes please
Not right now
Maybe
Has this Health & Lifestyle Assessment been insightful ?
*
Yes
No
Somewhat
Email
*
example@example.com
Submit & Receive My Lifestyle Feedback
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