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Name*
Mobile number*
How is your overall health ?
Poor Health
Generally doing okay
I am in excellent health
Please tick all conditions that apply to you
Thyroid
Diabetes/Pre-diabetes
BP
Cholesterol
PCOS
Anything else you would like to mention
Any other health conditions
Do you have any dietary restrictions?
How many hours of sleep on average every night ?
Less than 4 hours
4-5 hours
6 hours
7-8 hours
9 or more hours
How often do you feel tired or have difficulty staying awake during routine tasks in the day?
Not at all
Several days
More than half the days
Nearly every day
How often do you eat fast food, sugary drinks (e.g., soda, sports drinks, juice) or packaged foods (e.g., chips, candy, crackers, cookies)?
Not at all
Several days
More than half the days
Nearly every day
How many servings of whole fruits and vegetables do you eat every day (1 serving is about a handful and does not include fruit juice) ?
Less than 2 servings
2-3 servings
4-5 servings
More than 5 servings
What do you think about your current weight?
I want to gain weight
I am happy with my weight
I want to lose weight
How often do you exercise (e.g. brisk walking or enough movement to break a light sweat)?
Less than 1 time per week
1-2 times per week
3-4 times per week
5 or more times per week
How many minutes do you exercise on average ?
Less than 10 minutes
10-29 minutes
30-49 minutes
50 minutes or more
Please select the main areas you are most motivated to change.
Sleep
Exercise
Weight Management
Nutrition
Mental Health
What motivates you to be healthier?
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Contacts
LetSimplifyHealth@gmail.com
+44-7518739478
