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Holistic Health Score
To answer the questions, tick whichever option is appropriate based on your lifestyle
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* Indicates required question
Email
*
Your email
Name
Your answer
Age
*
Choose
18-25
26-35
36-45
46-55
55+
Gender
*
Male
Female
Name of the Organization
Your answer
How many hours of continuous undisturbed sleep do you get on most nights?
*
8-10 hours
6-8 hours
<6 hours
Erratic or disturbed sleep on many nights
How many days of physical exercise of 30 minutes or more do you do every week?
*
5-7 days/week
3-4 days/week
1-2 days/week
Irregular/Rare
How often do you eat green vegetables?
*
5-7 days/week
3-4 days/week
1-2 days/week
Irregular/Rare
How often do you eat fruits and nuts?
*
5-7 days/week
3-4 days/week
1-2 days/week
Irregular/Rare
How often do you eat a meal of packaged / processed / deep fried / junk / high sugar foods (sweets) or foods high in refined flour (Maida)?
*
Occasionally/Rarely
1-2 days/week
3-4 days/week
5-7 days/week
How many glasses or liters of water do you drink per day?
*
>2.5 liters (11-12 glasses)
2 to 2.5 liters (9- 10 glasses)
1 to 2 liters (4-8 glasses)
<1 liter (<4 glasses)
Do you suffer from any chronic disease (Diabetes, High Blood Pressure, Heart Disease/Coronary Artery Disease/Heart failure, Lung Disease/Asthma/COPD, Kidney/Liver disease, Anemia or Cancer)?
*
Do not suffer from any chronic disease
Suffer from Chronic Disease but well controlled in last 6 months
Suffer from Chronic Disease and not adequately controlled in last 6 months (required change/addition/increased dose of medicines at some point)
Suffer from Chronic Disease and not adequately controlled in last 6 months (required hospitalization, emergency care, or procedure or surgery at some point)
How often do you engage in de-stressing or relaxing activities (family time, socializing, hobbies)?
*
5-7 days/week
3-4 days/week
1-2 days/week
Erratic/Irregular/Rare
Do you Smoke/Consume tobacco, and/or have Alcohol (>twice/week)?
*
No
Only Alcohol > twice/week
Only Smoke/Consume tobacco
Both Smoke/Consume tobacco, and have Alcohol (>twice/week)
How often do you feel irritated, angry or abusive?
*
Occasionally/Rarely
1-2 days/week
3-4 days/week
5-7 days/week
How often do you feel mentally stressed, anxious, or depressed?
*
Occasionally/Rarely
1-2 days/week
3-4 days/week
5-7 days/week
Do you suffer from digestive complaints like acidity, nausea, constipation, diarrhea, abdominal pain, belching or bloating (gas)?
*
Occasionally/Rarely
Once a month
2-3 times/month
>once a week
How often have you suffered from fever, cough / cold / sore throat, body pain or severe fatigue in the last 6 months?
*
Never
Once
2 - 3 times
>3 times
In what range is your body weight considered to be in?
*
Underweight or thin
Normal range
Overweight but not obese
Obese or fat
On a scale of 1 - 10 (1 being worst and 10 being best), how will you rate , yourself, home and community surroundings on hygiene (cleanliness, access to sunlight / ventilation / fresh air, and presence of pests / insects)?
*
8 - 10
5 - 7
2 - 4
<2
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