ENERVARA General Wellness Assessment

ENERVARA General Wellness Assessment

Answer a few quick questions to understand your daily health habits and get your personalized wellness score.
Full Name*

PrefixFirst NameLast Name
Contact Number*
Email *
What is your age?*
What is your gender?*
Height*
Weight*
OCCUPATION*

SEDENTARYLIGHT ACTIVEHEAVY ACTIVE WORK
AVERAGE DAILY WATER INTAKE*

Less than 500 ml500 ml - 1 lts1-2 lts2-3 lts3-4 ltsMore than 5 lts
DIETARY PREFERENCE*

VEGETARIANNON VEGETARIANEGGETERIANVEGAN
Food Allergies
DAILY SLEEP HOURS*

4-5 hrs5-6 hrs6-7 hrs7-8 hrsMore than 8 hrs
Check the conditions that apply to you or any member of your immediate relatives:*

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyI dont have any of these conditionsOther
Check the symptoms that you' re currently experiencing:*

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalNoneOther
Are you currently taking any medication?*

YesNo
Please list them.
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How often do you consume junk/processed foods?*

Once in a weekTwice in a weekThrice in a weekMore than thrice a weekOther
How often do you have fruits and vegetables in your meals?*

Rarely (less than once a week)Occasionally (1-2 times per week)Sometimes (3-4 times per week)Often (5-6 times per week)Multiple times daily (in most meals)
How often do you get health check-ups done?*

NeverOnly when I feel unwellOnce in 2-3 yearsOnce a year (annual check-up)Every 6 months or more frequently
How many home-cooked meals vs. outside food do you eat weekly?*

Mostly home-cooked (0-1 outside meals per week)Home-cooked majority (2-3 outside meals per week)Balanced (about half home-cooked, half outside)Mostly outside food (5-6 outside meals per week)Almost all outside food (daily or more than 7 outside meals per week)
Should be Empty: