Personalized Health Assessment

Basic Information

First name

Last name

Phone number*

Email address*

Your Diet Infromation

1. What is your biological sex?*

Male
Female

2. Age?*

3. Height? (*cms)*

4. Weight*

5. How do you describe your diet?*

Vegan
Vegetarian
Non-Vegetarian
Other

6. Do you have any Allergies?*

Gluten
Lactose
Nuts & Peanuts
Other
Fish & Crustacean
No

7. How many meals do you usually intake in a day?*

< 2
3
> 3

8. How many liters of water do you drink in a day?*

< 3 Ltr
3 Ltr
> 3 Ltr

9. Do you drink alcohol? *

Yes
Occasionally
No

10, Do you smoke?*

Yes
Occasionally
No

Any Digestion Issue

11. Are you experiencing any issues below*

Bloating
Constipation
Diarrhoea
Heartburn or acid
None of these
Reflex

12. Have you recently been feeling tired or fatigued?*

Most days
Occasionally
Never

Energy Info

13. Do you experience tiredness in*

Early-morning
Mid-morning
Post-lunch

Stress & Sleep Details

14. Do you currently suffer from?*

Stress
Low mood
Anxiety / Worry
None

15. Recently, do you tend to find that you? *

Can’t fall asleep
Wake up a lot
Get insomnia
None of these

16. Over the past year, how often have you been unwell? (e.g, colds, flu and infections)*

2-3 times
Often
Never

Physical Exercise

17. How often do you exercise in a week?*

Never
<3
3 - 4 days
5+ days

18. What sort of exercise do you tend to do?*

Cardio
Strength
Core
Yoga
High-intensity interval training (HIIT)

Body Composition

19. Your aim is to*

Loose Weight
Gain Weight
Maintain Health and Weight
Improve Vit. & Min. Deficiencies

20. Do you suffer from a genetic, incurable or chronic condition?*

Yes
No

21. What is your medical diagnosis?

22. Are you currently taking any prescribed medication?*

Yes
No

23. Prescribed Medication Name and Dosage? (Enter below*)

24. Have you undergone any surgeries before?*

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