How Healthy Are You?

Health Survey

Please fill out this health survey to better understand your health needs.
Email
example@example.com
Name

First NameLast Name
Gender
Birth Date

MonthDayYear
What kind of Juice do you drink?*

Vegetable juice 100 %Mix Veggie juice > Fruit juiceMix Fruit Juice > Veggie juiceOnly Fruit
How many cups of coffee do you drink per day?*

0 - 1 cup2 – 3 cups4 – 5 cups>5 cups
What are your symptom after eating?*

NoneSleepyBloatingBoth sleepy and bloating
How many hours a day do you sleep?*

8 Hours7 Hours6 Hours< 6 hours Or > 8 Hours
Do you feel tired? If yes, when?*

NoYes. Only morning or AfternoonYes. Both Morning and AfternoonAll day
What type of your exercise you do?*

Cardio+ Weight training + YogaOnly 2 of the aboveOnly 1 kind of the aboveNever
Where is the fat storage in your body?*

No fat. Very leanOnly 1 part of the body2 parts of the body> 3 parts of the body
Health Score
The Health Score is calculated depending on the answer you selected.
Unhealthy

Your lifestyle leads to the risk of heart disease, cancer and etc. You may currently have a problem with adrenal fatigue and metabolic syndrome. Recommend to meet your physician for further check and advice on a lifestyle change.
Good

but still, need to improve. It looks like you’ve got an understanding of lifestyle principles. Good advice from health professionals for healthy lifestyle adjustments should benefit.

Check up is also recommended to look for your health condition and treatment plan for your optimal health.
Fantastic!

You do it well. Eating well and being physically active. Do keep on your good healthy lifestyle and check-up regularly, this will help to reduce the risk of disease.
Should be Empty:

Health Survey