Health Assessment Questionnaire

First name *

Last name *

Email *

Age

Weight

Height (cm)

Gender *

Female
Male
Other

Activity Level (required): (kopiera) *

Very inactive, bedridden
Sedentary work, no exercise
Sitting and standing work (or light daily exercise, such as brief walks)
Standing and mobile work (or engaging in regular exercise)
Standing and mobile work with occasional lifting (or exercising and strength training several times a week)
Mobile work with many heavy lifts (or extensive exercise and strength training)
Very intense physical labor (or elite athlete)

What is your marital status or family situation? *

Do you experience a good balance between work and leisure? (required) *

Are you satisfied with your job, including aspects like your boss, colleagues, and tasks? (required) *

If you work, how many hours per week do you work? (Please enter the number of hours)

How long do you usually spend eating breakfast on weekdays? (required) *

How long do you usually spend eating lunch on weekdays? (required) *

How long do you usually spend eating dinner on weekdays? (required) *

Where and how do you usually eat your lunch on weekdays? (required) *

Company’s lunch restaurant
Lunch restaurant outside the company
Packed lunch in the lunchroom
Purchased lunch in the lunchroom
Packed lunch from home at your personal workspace
Eat lunch at home
Purchased lunch at your personal workspace
Do not eat a full lunch
Do not eat lunch at all

How hearty/big is your breakfast usually for you? (required) *

How hearty/big is your lunch usually for you? (required) *

How hearty/big is your dinner usually for you? (required) *

How nutritious is your breakfast usually for you? (required) *

Not nutritious
Quite nutritious
Very nutritious
Do not eat this meal

How nutritious is your lunch usually for you? (required) *

Not nutritious
Quite nutritious
Very nutritious
Do not eat this meal

How nutritious is your dinner usually for you? (required) *

Not nutritious
Quite nutritious
Very nutritious
Do not eat this meal

Describe a typical food day for you on a weekday. (required) *

Please provide a detailed description of a typical day’s meals for you, including breakfast, lunch, dinner, and all snacks. Include estimated amounts for each item. For example: Breakfast: about 300 ml of plain, full fat yogurt, 1 tbsp of honey, some nuts, 1 portion of granola, 1 boiled egg…

What do you drink in a day? *

Please estimate everything you drink and the quantities (e.g., water: about 1.5 liters, coffee: 3 cups, orange juice: 1 glass, etc.

How would you rate your health right now? (required) *

How frequently do you feel tired or lack energy during the day? (required) *

How often do you feel guilty about what you eat? (required) *

How much do you agree or disagree with the following statement "I like to have an extra cup of coffee."? (required) *

How much do you agree or disagree with the following statement "I try to eat fruit or berries between meals."? (required) *

How much do you agree or disagree with the following statement "I avoid fatty foods."? (required) *

How much do you agree or disagree with the following statement "I enjoy eating fatty foods."? (required) *

How much do you agree or disagree with the following statement "I eat large amounts of fresh vegetables"? (required) *

How much do you agree or disagree with the following statement "I live to eat."? (required) *

How much do you agree or disagree with the following statement "Eating is a necessary evil/it's boring to eat/think about food."? (required) *

How much do you agree or disagree with the following statement "I love sandwiches and bread."? (required) *

How much do you agree or disagree with the following statement "I try to eat fresh vegetables every day."? (required) *

How much do you agree or disagree with the following statement "I try to diet and loose weight now and then."? (required) *

How much do you agree or disagree with the following statement "My dinner often consists of ready-made meals that just need to be heated."? (required) *

How much do you agree or disagree with the following statement "I eat out most days"? (required) *

How much do you agree or disagree with the following statement "Almost all my meals are cooked at home""? (required) *

How much do you agree or disagree with the following statement "I mostly try to eat healthy food."? (required) *

How much do you agree or disagree with the following statement "I eat when I'm stressed."? (required) *

How much do you agree or disagree with the following statement "I easily over eat in the evenings."? (required) *

How much do you agree or disagree with the following statement "I bing eat when I'm alone" or "I hide from others how much I eat"? (required) *

How much do you agree or disagree with the following statement "I snack between meals."? (required) *

How much do you agree or disagree with the following statement "I avoid food with high sugar content."? (required) *

Which way(s) of eating best describe you right now? Choose one or more options, (required)

Even if there’s not a perfect option, pick one or more that best describe your way of eating.

How often do you drink alcoholic beverages (such as wine, spirits, or strong beer)? (required) *

Do you smoke tobacco? (required) *

No
Yes, daily
Yes, at parties
I have just quit

How often do you eat snacks (like potato chips, cheese puffs, peanuts, etc.)? (required) *

How often do you eat candy and sweets (including candy bars, sugary protein bars, pastries, etc.)? (required) *

How stressed do you feel? (required) *

Do you feel like you get enough sleep at night? (required) *

No, not at all
No, hardly
Yes, mostly
Yes, absolutely

How many hours do you sleep per night on average? *

How many times do you exercise on average per week? (required) *

Exercise is some physical activity leading to increased heart rate lasting more than 30 minutes. It can be fast walking/power walk, free dance, Yoga, Gym and cycling.

What physical activity/activities do you perform?

How often do you experience nausea? (required) *

How often do you experience chest pain? (required) *

How often do you experience pain in and/or shoulders and neck? (required) *

How often do you experience general muscle or joint pain? (required) *

How often do you experience headaches/migraines? (required) *

How often do you experience colds/infections? (required) *

How often do you experience stomach/intestinal problems? (required) *

How often do you experience sleep disturbances? (required) *

How often do you experience anxiety, worry, or fear? (required) *

How often do you experience hopelessness or depression? (required) *

How often do you experience frustration or anger? (required) *

If you are a woman, describe your cycle and any symptoms that you think/know are linked to your cycle and/or any other issues that you think/know are related to hormones.

Ex: regular menstruation, irregular, heavy bleeding, PMS, PMDS, menopause, peimenopause, hot flashes, sweating, sleep problems, fertility issues etc.”). Also mention other hormonal issues such as thyroid issues. If you have had your hormone levels tested, mention that.

If you are a man, mention any symptoms that you think can be related to hormonal imbalance.

Some symtoms are sudden, unexplained weight loss or gain, low energy, thyroid issues, aggressiveness, depression, muscle loss, irritability, prolonged fatigue, fertility issues, lowered libido and so on. If you have had your hormone levels tested, mention that.

Do you have any disease, medical diagnosis, allergies, or similar?

Do you take prescription medications regularly? If so, which ones, for what, and how often?

E.g., over-the-counter drugs from the pharmacy such as cold medicine, allergy medicine, painkillers, etc.

Have you sought alternative care before, and in that case what diagnosis or analysis have you received? (briefly as you perceive it)

E.g., Traditional Chinese Medicine, Ayurveda, Functional Medicine Testing, etc.

Do you take non-prescription medications regularly? If so, which ones, for what, and how often?

E.g., over-the-counter drugs from the pharmacy such as cold medicine, allergy medicine, painkillers, etc.

Do you take dietary supplements or herbal medicines? If yes, which ones, and why?

On a scale of 1-10, how motivated or inspired do you estimate that you are to implement the changes that may be needed to feel better? (1 = Not at all, 10 = Very motivated)

Do you feel that someone or something constitutes an obstacle for you in implementing the changes you want? If so, what or who?

For example: time, money, family situation, work situation, peer pressure, energy levels, health status and so on.

What goals or outcomes do you hope to achieve through this health program?" *

Is there anything your would like to add?