(Automation) LVC50

Vitality and Longevity Calculator:

50 Questions
⚠️ Beta Test Disclaimer – Please Read Carefully:

⚠️ Beta Test Disclaimer – Please Read Carefully This form is part of a Beta Test and is intended solely for testing and development purposes. Please do not enter any Personal Health Information (PHI), including medical conditions, diagnoses, or other identifiable health details. To protect your privacy and comply with applicable regulations, we ask that all submissions remain anonymous and free of sensitive data. By participating in this beta test, you acknowledge and agree to the following: You understand what constitutes Protected Health Information (PHI) under HIPAA. You acknowledge that this form and associated workflows are part of a beta test and not part of a finalized, HIPAA-compliant product. You agree not to submit any PHI or sensitive personal health information. You consent to the use of your non-identifiable input for the purpose of product testing, feature refinement, and internal development only. You understand that while JotForm offers HIPAA-compliant features, certain downstream automation steps (e.g., third-party tools like Zapier, GPT, or Google Docs) have not yet been fully validated for HIPAA compliance.🔒 If you do not agree to these terms, or if you intend to submit PHI, please do not participate in this beta test. AlphaWell360 is committed to protecting privacy and building secure, ethical systems. We thank you for your participation and support in helping us shape a powerful tool for future wellness journeys.
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Welcome

Below you will find the AlphaWell360 Vitality and Longevity Calculator 50, a thoughtfully designed tool to help you better understand your health, well-being, and potential for a longer, more vibrant life. Completing this questionnaire is an important step toward optimizing your vitality and longevity. Take a few moments to invest in your health and well-being. Your journey toward a healthier, more fulfilling life starts now!
Foundational Wellness
Q1 - I attend regular medical check-ups to monitor and maintain my health, including preventative dental care such as regular cleanings and check-ups.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q2 - I follow consistent wellness routines and practices that help me maintain balance in my daily life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q3 - I feel confident in my ability to manage my long-term health and maintain overall wellness.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q4 - I always get at least 7-9 hours of high-quality sleep and feel refreshed and energized throughout the day.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q5 - I engage in preventative dental care, including regular cleanings and check-ups.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q6 - I understand my personal health risks, including hereditary, lifestyle, and behavioral risks.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q7 - I maintain an ideal body weight within the healthy range for my height and age.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q8 - I regularly track personal health indicators, such as sleep, activity, or hydration, to stay informed.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q9 - I avoid unnecessary exposure to toxins within my environment by using devices like water filters, air purifying systems, etc., and avoiding things like tap water, microplastics, harsh chemicals in my household products, etc.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q10 - I am proactive about seeking medical attention when I notice unusual symptoms.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Physical Wellness
Q11 - I engage in regular physical activity, including aerobic, strength, or flexibility exercises, most days of the week.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q12 - My exercise routine is varied and includes activities that promote cardiovascular health, muscle strength, and balance.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q13 - I consistently consume a diet rich in fruits, vegetables, whole grains, and lean proteins.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q14 - I limit my intake of processed foods, sugary beverages, and fast foods to maintain optimal health.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q15 - I drink little or no alcohol to support my overall well-being.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q16 - I avoid smoking and the use of tobacco products to reduce my risk of disease.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q17 - I stay adequately hydrated throughout the day by drinking at least eight 8-ounce glasses of water.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q18 - I take active steps to maintain strong and healthy bones, such as consuming calcium-rich foods and doing weight-bearing exercises.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q19 - I engage in recreational physical activities that bring me joy, such as dancing, swimming, or cycling.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q20 - I wear a fitness tracker that measures my vitals, HRV, and sleep quality, and I use this data to improve my physical conditioning.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Mental Wellness
Q21 - I have a clear sense of purpose or meaning in life that motivates me daily.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q22 - I am confident in my ability to effectively manage stress in both short-term and long-term situations.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q23 - I regularly practice stress-reducing techniques, such as meditation, physical activity, or deep breathing.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q24 - I participate in activities that challenge and stimulate my mind, such as reading, problem-solving, or learning new skills.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q25 - I feel mentally sharp and rarely experience significant cognitive lapses.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q26 - I consciously avoid negative thinking patterns and focus on positive aspects of life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q27 - I feel a sense of accomplishment in my work and personal pursuits.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q28 - I actively work on improving my emotional intelligence and empathy.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q29 - I can focus for long periods of time without being distracted, and I take breaks to avoid mental fatigue.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q30 - I regularly reflect on my personal growth and take actionable steps to improve myself.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Emotional Wellness
Q31 - I am satisfied with the balance between my work responsibilities and personal life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q32 - My work and daily activities contribute positively to my overall well-being and sense of purpose.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q33 - I regularly participate in meaningful community or volunteer activities that provide a sense of connection.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q34 - I spend quality time with close friends or family members on a regular basis.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q35 - I feel safe, valued, and supported in my personal relationships.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q36 - I often experience gratitude and take time to reflect on the positive aspects of my life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q37 - I laugh often and find joy in small moments throughout my day.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q38 - I am resilient and able to manage emotional challenges or setbacks effectively.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q39 - I practice self-compassion and treat myself with kindness during difficult times.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q40 - I generally feel calm, cool, and collected even in stressful situations and have a sense of pride in my ability to manage my emotions.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Other Wellness
Q41 - I believe my age does not limit my ability to live a vibrant and fulfilling life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q42 - I support my wellness with nutrient-rich foods and safe, evidence-informed supplements.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q43 - I spend time outdoors regularly, which rejuvenates me and enhances my mental and physical health.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q44 - I prepare and eat healthy home-cooked meals more often than relying on restaurant or prepackaged foods.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q45 - I take vacations or breaks that allow me to recharge and de-stress.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q46 - I live in a home environment that is clean, organized, and free of clutter.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q47 - I have financial security and feel confident in my ability to manage finances effectively.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q48 - I participate in spiritual or faith-based practices that align with my values.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q49 - I have a strong sense of spirituality and/or religion that positively influences my life.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Q50 - I am living a purposeful life and actively follow my dreams to achieve fulfillment.*

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Thank you for completing the Vitality and Longevity Questionnaire and sharing your reflections. Your input will guide us in creating a personalized plan to support your journey to wellness.
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