Health Survey

Hello there!

We created this template as a quick showcase of our work. Reviewing and submitting it will give you a clear picture of how Genetcat Solution Pty Ltd can partner with you to build a digital solution that will transform and expand your business.

Name (optional)

First NameLast Name
Your company name
Email

Health Survey

Please fill out this health survey
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contacts
Birth Date (optional)

MonthDayYear
Age (optional)
Ex:23
Gender (optional)

BMI
Height
Height in inches
Weight
Weight in lbs
What is your current BMI number?
What is the BMI value for the weight you want to maintain at?

Sleep
In general, at what time do you go to bed?
In general, when do you wake up?
On average, how many hours of sleep do you get?
Do you wake up feeling rested?

Other
How is the quality of your sleep?

Hydration
In a day, how much water do you drink usually?
In a day, how much coffee do you drink usually?
In a week, how much alcohol do you consume usually?

Stress
What do you do for work?
Do you enjoy what you do?
Are there any other stress in your life?

Rate your overall stress level

	1	2	3	4	5

1 is Lowest, 5 is Highest

Eating Habits
When do you eat your first meal?
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, what do you snack on?
How often do you eat out in a week?

Other
Where do you typically eat out?

Type a question
Should be Empty: