ENERVARA Emotional Wellbeing Check
Discover your mental wellness score and get personalized tips for balance, focus, and emotional wellbeing
Full Name
*
Mr.
Mrs.
Prefix
First Name
Last Name
Contact Number
*
Email
*
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Height
*
Weight
*
OCCUPATION
*
SEDENTARY
LIGHT ACTIVE
HEAVY ACTIVE WORK
AVERAGE DAILY WATER INTAKE
*
Less than 500 ml
500 ml - 1 lts
1-2 lts
2-3 lts
3-4 lts
More than 4 lts
DIETARY PREFERENCE
*
VEGETARIAN
NON VEGETARIAN
EGGETERIAN
VEGAN
Food Allergies
DAILY SLEEP HOURS
*
4-5 hrs
5-6 hrs
6-7 hrs
7-8 hrs
More than 8 hrs
Less than 4 hrs
Check the conditions that apply to you or any member of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
I dont have any of these conditions
Other
Check the symptoms that you' re currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
None
Other
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
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?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
How often do you feel stressed or anxious?
*
Never
Rarely ( a few times a month)
Sometimes ( a few times a week)
Often (almost every day)
Always (daily, most of the time)
Do you face frequent mood swings or irritability?
*
Never
Rarely ( a few times a month)
Sometimes ( a few times a week)
Often ( almost every day )
Always (daily, most of the time)
How many hours a week do you spend on screen (phone/laptop)?
*
Less than 10 hours (very low)
10-20 hours (low)
21-35 hours (moderate)
36-50 hours (high)
More than 50 hours ( very high)
Do you practice mindfulness, yoga or meditation?
*
Never
Rarely (once or twice a month)
Sometimes (1-2 times per week)
Often (3-4 times per week)
Regularly (daily practice)
How often do you engage in hobbies/social interaction?
*
Never
Rarely ( once or twice a month)
Sometimes (once a week)
Often (a few times a week)
Very often (almost daily/daily)
Submit
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