Overall Health Assessment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

Your full name *

Do you have any kind of diseases/discomforts in the body or mind? *

Yes, and it has significantly affected my daily routine negatively

Yes, and it has affected my daily routine to some extent negatively

Yes, but it does not affect my daily routine negatively

No, I don’t have any kind of diseases/discomforts

Has the build of your body changed drastically in the recent past or over a period of time? (Compared to how you were in your younger days has your size, body build increased or decreased drastically now?) *

Yes, there’s a major change in the build of my body without specific efforts taken for it

Yes, there’s moderate alteration in the build of my body without specific efforts taken for it

No, there’s only a mild alteration in the build of my body without specific efforts taken for it

Yes, there’s a change in the build of my body after specific efforts taken for it (diet correction, exercises) and I feel healthier now

Yes, there’s a change in the build of my body after specific efforts taken for it (diet correction, exercises) but I don't feel healthy now

No, I have always had the same kind of body build

Has your complexion majorly changed in the recent past? (Was it very different in your younger/earlier days?) *

Yes, there's majorly altered complexion on most parts of my body

Yes, majorly altered complexion in some parts and/or mild/moderate alteration in the complexion in some other parts

No, there’s only mild/moderately altered body colour in some parts

No, my complexion has always been the same (or minor changes in correspondence to age)

Has your strength, energy and efficiency changed over a period of time or recently? (If yes, what is the approximate change?) *

Yes, my strength, energy and efficiency has decreased by more than 50% now. I had more strength earlier.

Yes, my strength, energy and efficiency has decreased up to 50%. I had more strength earlier.

My strength has reduced to some extent but my efficiency hasn’t been altered (less than 25% reduction)

No, my strength and efficiency has been good or any change is minor and according to age

What has your hunger been like in the past couple weeks? *

I don’t feel hungry at all

I feel hungry at meal time but don’t feel like eating food

I feel hungry at meal time but cannot eat in proper quantities

I feel hungry at meal time and can eat in proper quantity

Do you have willingness to eat food? (How has it been generally in the past couple weeks) *

I don’t feel like eating food but I have difficulty while taking it

I don’t feel like eating food but can take it without difficulty

I have willingness for the food I like the most, but not for others

I have willingness towards some specific foods or only one type of taste (like sweet, salty or sour)

Equal willingness to eat all kinds of food

How many of these signs do you notice after a few hours of taking a meal - clear burp, surge in energy, lightness in the body, hunger and thirst? *

I do not observe any of these signs or notice one sign occasionally (less than 25% of times)

I observe some of these signs sometimes ( 25 to 50 % of times)

I observe a lot of these signs ( 50 to 90 % of times)

I experience all of these signs mentioned (more than 90% of times)

When do you notice these signs approximately after taking a meal – clear burp, surge in energy, lightness in body, hunger and thirst? *

I notice these signs after more than 10 hrs of having a meal

I notice these signs around 8-10 hrs of having a meal

I notice these signs within 6-8 hrs of having a meal

I notice these signs less than 6 hrs of having a meal

Do you have any difficulty passing flatus/gases/wind? *

Yes, I can’t pass flatus if I get an urge or I pass with great difficulty, with loud sound and/or very foul smell

Yes, I have some difficulty in passing flatus, frequency is high (more than 10 times a day), with sound or may be foul smelling

Yes, I have a little difficulty, slightly higher frequency with or without mild sound and/or slight odor

No, easily pass flatus if I get an urge, very less frequency (less than 2-3 times a day), without sound or odor

Which of these apply to you? *

Male: Premature / Delayed ejaculation with severe pain or no ejaculation

Male: Premature / delayed ejaculation, may be with mild pain

Male: Sometimes Premature / Delayed ejaculation with or without pain

Male: Timely ejaculation without pain

Female: Irregular cycles, severe pain, very scanty / heavy bleeding

Female: Severe alteration in any one parameter mentioned above or moderate change in all the parameters

Female: Mild to moderate alteration in any of the parameters mentioned above

Female: Regular, no pain, moderate amount of bleeding

Do you have any difficulty in passing urine? *

Yes, I have great difficulty in passing urine (passes in broken stream or with lot of pressure or with lot of burning), with altered consistency (cloudy/thicker/turbid) and changed color of urine

Yes, I have some difficulty in passing urine (as mentioned above), but consistency and color of urine may or may not be altered

No, I have no difficulty, but the frequency is quite high (more than 7-8 times a day)/quite low (less than 3-4 times a day)

No, I pass easily, at a normal routine frequency

Do you have difficulty in evacuating your bowels (passing stools) normally? (How has it been in the past couple months?) *

Yes, I can pass stools only after taking purgatives/laxatives

I can pass stools but only after smoking, consuming tea/hot drinks, walking etc

I can pass stools without any help but it is irregular and with or without satisfaction

I can pass stools easily (without any help) and regularly with satisfaction

What would you say is your performance level in these respects now– thinking clearly, planning, processing information, proper analysis of any thought, concentrating/focusing? *

I am not able to perform in more than 3 of these aspects satisfactorily

I am not able to perform in 2 or 3 of these aspects satisfactorily

I am not able to perform very well in one of the aspects mentioned satisfactorily

I am able to perform my best in all the aspects satisfactorily

Do you get disturbing or bothersome dreams? *

I regularly get abnormal and/or disease related dreams disturbing my sleep

I occasionally get abnormal dreams but it may disturb my sleep

I occasionally get abnormal and disease related dreams but it does not disturb my sleep

I rarely get abnormal or disease related dreams but it never disturbs my sleep

When you wake up in the morning, how do you feel? *

I mostly feel distressed at both physical & mental levels after waking up in the morning

I have feelings of discomfort at physical level or dissatisfaction at mental level after waking up in the morning

I have feelings of mild dissatisfaction without any complaint at physical level after waking up in the morning

I feel satisfied and fresh at physical & mental levels after waking up in the morning

How long does it take to fall asleep after you go to bed? *

It takes more than 1 hour to fall asleep after going to bed and trying to sleep in any condition

It takes between 30 minutes to 1 hour to fall asleep after going to bed and trying to sleep in any condition

It takes between 5 to 30 minutes to sleep after going to bed and trying to sleep in any condition

It takes less than 2 minutes to fall asleep in any condition

Has the quality or loudness of your voice changed abnormally recently or over a period of time? *

Yes, the quality and loudness of my voice has greatly altered from what my normal voice was

Yes, either the loudness or quality of my voice is greatly altered from how my normal voice used to be

Yes, the loudness and/or quality of my voice is mildly altered from how my normal voice used to be

No, the quality and loudness of my voice has always been the same, or change in voice has been because of puberty

Have you noticed any changes to the perception of information through any of your senses? (Smell, taste, vision, touch, hearing) *

Yes, I am unable to perceive any information through one or more of my senses

Yes, I have a severe difficulty in perceiving through one or more of my senses

Yes, I have mild/moderate difficulty in using one or more of my senses

No, I have normal perception through all my senses

Do you face any difficulty with decision making? (If you are in a situation where you have to take any decision, how do you feel?) *

Yes, I cannot make decisions at all and/or depend on others to take decisions for me

Yes, I feel greatly bewildered and can make a decision only after seeking help from others

I feel confused while making decisions but I am able to judge well in the end

No, I can make decisions very well

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms