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42Questions
  • 1
    Select one
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  • 2
    Select one
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  • 3
    Beer, wine, spirits, etc
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  • 4
    (0, 1-2, 3-6, 7-10, 10+)
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  • 5
    Select one or more.
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  • 6
    Select one or more.
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  • 7
    Bad sleep, fatigue, depression, anxiety, upset stomach, loose stools, etc
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  • 8
    not duration, how deeply do you sleep? do you wake up often?
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    Bad
    Great
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  • 9
    Do you feel tired? Does it take you a long time to wake up?
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  • 10
    i.e. I feel rested upon waking, but get tired around 3pm
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  • 11
    Pick an option
    Please Select
    • Please Select
    • Never
    • Sometimes
    • Regularly
    • All of the time
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  • 12
    Multiple choice
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  • 13
    1 - Never, 3 - Most of the time, 5 - 7 days a week
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    • 5
    Never
    Everyday
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  • 14
    Multiple choice
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  • 15
    (Less than 30 mins, 30-60 mins, More than 1 hour)
    Please Select
    • Please Select
    • 15 mins
    • 30 mins
    • 45 mins
    • 60 mins
    • 90 mins
    • 120 mins
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  • 16
    Multiple choice
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  • 17
    Soy allergy, Coeliac, Diabetes
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  • 18
    (e.g., sauerkraut, kimchi, yogurt)
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  • 19
    i.e sauerkraut, kimchi, soy sauce, yoghurt, sourdough
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  • 20
    E.g Magnesium, Creatine, Ashwaghanda
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  • 21
    Multiple line
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    quoteCreated with Sketch.
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  • 22
    i.e. Do you feel lonely, do you have regular social interaction
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  • 23
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  • 24
    Please list, examples include: Psychologist, Psychiatrist, Counsellor, Psychotherapist,
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  • 25
    i.e Crowds, Card declining at the check out etc
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  • 26
    i.e Bipolar, Low-sodium, Arthritis
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  • 27
    I work better with a practitioner of the same gender, I prefer someone that is also Muslim etc.
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  • 28
    I prefer people to use my preferred name "Jamie" instead of my birth name James
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  • 29
    i.e. I do not feel safe to sleep
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  • 30
    i.e. Ikigai, I feel valued
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  • 31
    Pain that lasts longer than 14 days
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  • 32
    Coffee, Energy drinks, Caffeinated tea's, etc
    Please Select
    • Please Select
    • 0
    • 1
    • 2
    • 3
    • 4+
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  • 33
    How easy or challenging do you find eating?
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  • 34
    Select one
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  • 35
    When it comes to bed time, on lunch break can you unwind?
    Please Select
    • Please Select
    • Never
    • Rarely
    • Sometimes
    • Most of the time
    • All of the time
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  • 36
    How often are you happy?
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    • Never
    • Sometimes
    • Most of the time
    • All of the time
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  • 37
    Mood swings are characterized by high highs transitioning into lows
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  • 38
    In Liters
    Please Select
    • Please Select
    • 1L
    • 2L
    • 3L
    • 4L+
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  • 39
    i.e I would like to do more exercise, I am struggling to lose weight
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  • 40
    What would you like to achieve?
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  • 41
    I understand that my answers will be stored anonymously and may be used to help shape wellness programs and practitioner education within the Equinox Co-operative. My data will never be sold or linked back to my identity.
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  • 42
    Select one or more
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  • 43
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  • 44
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