Assessment form and reporting

Health Assessment

A Health Assessment is a personalized evaluation of your overall well-being, based on your lifestyle and medical history. It provides insights into potential health risks and offers tailored recommendations to help you improve and maintain your health.

Health Assessment Form

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- Step 1 of 6

How many meals do you typically consume in a day? *

1
2
3
More than 3

If you consume less than 2 meals a day, how does it affect your energy levels? *

I feel tired all day
I experience energy dips
No significant effect
I feel energetic

How often do you consume fruits and vegetables? *

Rarely
1-2 times a week
3-4 times a week
Daily

If you rarely consume fruits and vegetables, what are the main barriers? *

Rarely
1-2 times a week
3-4 times a week
Daily

How many glasses of water do you drink each day? *

Less than 4
4-6
7-9
10 or more

How many hours of sleep do you get on average? *

Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours

If you sleep less than 5 hours a night, how does it impact your mood or productivity? *

I feel irritable and unproductive
I struggle to focus
No noticeable impact
I still function well

How often do you engage in physical exercise? *

Rarely
1-2 times a week
3-4 times a week
5 or more times a week

If you rarely exercise, what prevents you from being more active? *

Lack of time
Lack of motivation
Physical limitations
No interest in exercise

How do you feel after meals? *

Energetic: 4 points
Sluggish: 1 point
No significant change: 2 points
Bloated or uncomfortable: 1 point

How often do you skip meals? *

Daily
2-3 times a week
Once a week
Rarely

If you often feel sluggish after meals, what do you attribute it to? *

Overeating
Poor food choices
Digestive issues
No idea

How often do you feel hungry between meals? *

Frequently
Occasionally
Rarely
Never

How often do you feel stressed? *

Constantly
Frequently
Occasionally
Rarely

If you feel stressed frequently, how does it affect your sleep or appetite? *

I have trouble sleeping:
My appetite decreases
My appetite increases
No noticeable effect

How do you typically manage stress? *

I don’t manage it
Exercise
Meditation
Talking to someone

How often do you feel joyful or content? *

Rarely
Occasionally
Frequently
Almost always

If you rarely feel joyful, what do you think is the main reason? *

Work or academic stress
Lack of social life
Health issues
No clear reason

How satisfied are you with your current work-life balance?

Very dissatisfied
Somewhat dissatisfied
Satisfied
Very satisfied

If you are dissatisfied with your work-life balance, what is the primary cause? *

Long working hours
Lack of time for personal interests
High job demands
Lack of flexible work options

How often do you feel lonely or isolated? *

Frequently
Occasionally
Rarely
Never

If you feel isolated, how does this affect your overall mood? *

I feel more depressed
I feel anxious
I feel unmotivated
No significant impact

How often do you spend quality time with loved ones? *

Rarely
Occasionally
Frequently
Almost always

Do you feel supported by your social circle? *

Not at all
Sometimes
Mostly
Always

How often do you engage in activities that make you happy? *

Rarely
Occasionally
Frequently
Almost always

How often do you worry about things you cannot control? *

Constantly
Frequently
Occasionally
Rarely

If you worry frequently, how does this impact your physical health? *

I experience headaches or muscle tension
My digestion is affected
I get sick more often
No noticeable impact

How often do you take breaks during work or study? *

Never
Rarely
Sometimes
Frequently

How often do you engage in spiritual or mindfulness practices? *

Never
Occasionally
Frequently
Daily

If you rarely engage in spiritual practices, what are the main barriers? *

Lack of time
Lack of interest
Don’t know where to start
Not a priority

How important is spirituality or mindfulness in your life? *

Not important
Somewhat important
Important
Very important

How satisfied are you with your current spiritual or mindfulness practices? *

Not satisfied
Somewhat satisfied
Satisfied
Very satisfied

How concerned are you about environmental issues? *

Not concerned
Somewhat concerned
Concerned
Very concerned

If you are concerned about environmental issues, what actions do you take? *

Recycling
Reducing waste
Conserving energy
Volunteering

How often do you take actions to reduce your environmental impact? *

Never
Occasionally
Frequently
Almost always

Which of the following best describes your spiritual practices? *

I don’t have any
Meditation or prayer
Attending religious services
Reading spiritual texts

How often do you participate in community or environmental activities? *

Never
Occasionally
Frequently
Almost always

If you don’t participate in community activities, what prevents you? *

Lack of time
No interest
No opportunities nearby
Don’t see the value

Do you feel a connection with nature? *

Not at all
Sometimes
Frequently
Always

If you feel disconnected from nature, what would help you feel more connected? *

Spending more time outdoors
Gardening or nature-based hobbies
Learning about the environment
Engaging in conservation activities

How satisfied are you with your contributions to environmental sustainability? *

Not satisfied
Somewhat satisfied
Satisfied
Very satisfied

How often do you reflect on your personal values and beliefs? *

Never
Occasionally
Frequently
Almost always

If you rarely reflect on your personal values, what prevents you? *

Lack of time
Uncertainty about what to reflect on
Discomfort with self-reflection
No clear reason

How confident are you in managing your finances? *

Not confident
Somewhat confident
Confident
Very confident

If you are not confident in managing finances, what challenges do you face? *

Lack of knowledge
Lack of resources
Debt or financial obligations
Unpredictable income

what you of

How often do you worry about your financial situation? *

Constantly
Frequently
Occasionally
Rarely

If you frequently worry about finances, how does this impact your mental health or sleep? *

I have trouble sleeping
I feel anxious or stressed
It affects my mood
No noticeable impact

How satisfied are you with your current financial situation? *

Very dissatisfied
Dissatisfied
Satisfied
Very satisfied

How often do you budget or track your expenses? *

Never
Occasionally
Frequently
Always

How satisfied are you with your current job or occupation? *

Very dissatisfied
Dissatisfied
Satisfied
Very satisfied

If you are dissatisfied with your job, what are the main reasons? *

Lack of growth opportunities
High stress
Poor work-life balance
Low job satisfaction

How often do you feel stressed about work? *

Constantly
Frequently
Occasionally
Rarely

How well do you balance your work and personal life? *

Very poorly
Poorly
Well
Very well

If you have poor work-life balance, what contributes to this? *

Long working hours
High job demands
Lack of time for personal interests
Inflexible work schedule

How satisfied are you with your career growth? *

Very dissatisfied
Dissatisfied
Satisfied
Very satisfied

If you feel unprepared for retirement, what are the barriers? *

Lack of savings
Uncertainty about retirement planning
High current expenses
No retirement plan

How often do you save for the future or invest? *

Never
Occasionally
Frequently
Always

How prepared do you feel for retirement or long-term financial goals? *

Not prepared
Somewhat prepared
Prepared
Very prepared

How many hours do you spend on screens daily (work + leisure)? *

Less than 2 hours
2-4 hours
5-7 hours
More than 7 hours

If you spend more than 7 hours on screens daily, how does it impact your physical or mental health? *

I feel physically tired
I feel mentally exhausted
It disrupts my daily routine
No noticeable impact

How often do you feel overwhelmed by your screen time? *

Constantly
Frequently
Occasionally
Rarely

If you feel overwhelmed by screen time, what steps do you take to manage it? *

I don’t manage it
I take regular breaks
I limit my screen time
I engage in digital detox

How often do you take breaks from screens? *

Never
Occasionally
Frequently
Always

If you rarely take breaks from screens, what prevents you? *

Work demands
Habit
Lack of awareness
No interest in breaks

How often do you engage in digital detox (intentional breaks from technology)? *

Never
Occasionally
Frequently
Always

How does screen time affect your sleep? *

It disrupts my sleep
It slightly affects my sleep
No noticeable impact
It helps me relax before bed

If screen time affects your sleep, what do you attribute it to? *

Using screens before bed
Work-related stress
Social media usage
Watching videos or shows

How satisfied are you with your current screen usage habits? *

Very dissatisfied
Dissatisfied
Satisfied
Very satisfied

If you are dissatisfied with your screen usage habits, what changes would you like to make? *

Reduce overall screen time
Take more frequent breaks
Engage in more non-digital activities
Limit usage before bed:

How often do you feel the need to be constantly connected? *

Always
Frequently
Occasionally
Rarely

How often do you experience eye strain or headaches due to screen use? *

Constantly
Frequently
Occasionally
Rarely

How often do you engage in non-digital hobbies? *

Never
Occasionally
Frequently
Almost always

How often do you feel distracted by digital notifications? *

Constantly
Frequently
Occasionally
Rarely

How informed do you feel about sexual health? *

Not informed
Somewhat informed
Informed
Very informed

If you are not informed about sexual health, what are the main barriers? *

Lack of resources
Discomfort with the topic
Lack of time
No interest

How satisfied are you with your sexual health? *

Very dissatisfied
Dissatisfied
Satisfied
Very satisfied

How often do you experience challenges with sexual wellness? *

Constantly
Frequently
Occasionally
Rarely

If you experience challenges with sexual wellness, how does it affect your overall well-being? *

It causes stress or anxiety
It affects my relationships
It impacts my confidence
No significant impact

How often do you communicate with your partner about sexual health? *

Never
Occasionally
Frequently
Always

If you rarely communicate with your partner about sexual health, what prevents you? *

Discomfort
Fear of judgment
Lack of knowledge
No issues to discuss

How comfortable are you discussing sexual wellness with a healthcare provider? *

Not comfortable
Somewhat comfortable
Comfortable
Very comfortable

How often do you seek information or resources on sexual health? *

Never
Occasionally
Frequently
Almost always

How often do you feel that stress impacts your sexual wellness? *

Constantly
Frequently
Occasionally
Rarely

If stress impacts your sexual wellness, how do you manage it? *

I don’t manage it
I talk to my partner
I practice stress-relief activities
I seek professional help

How often do you engage in practices that promote sexual wellness (e.g., regular check-ups, healthy lifestyle)? *

Never
Occasionally
Frequently
Almost always

If you rarely engage in sexual wellness practices, what are the barriers? *

Lack of time
Discomfort with the topic
Lack of awareness
No need

How often do you feel satisfied with your level of intimacy? *

Rarely
Occasionally
Frequently
Almost always

How often do you think about improving your sexual wellness? *

Never
Occasionally
Frequently
Almost always

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