Holistic Health Score
To answer the questions, tick whichever option is appropriate based on your lifestyle


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Email *
Name
Age (as on last birthday) *
Gender *
Name of the Organization
How many hours of continuous undisturbed sleep do you get on most nights? *
How many days of physical exercise of 30 minutes or more do you do every week? *
How often do you eat green vegetables? *
How often do you eat fruits and nuts? *
How often do you eat a meal of packaged foods / processed foods / deep fried foods / junk food / high sugar foods (sweets) or foods high in refined flour (maida)? *
How many glasses or liters of water do you drink per day? *
Do you suffer from any chronic disease? These include Diabetes, Hypertension (HighBP), Heart Disease (Coronary Artery Disease, Heart failure, Heart rhythm problems-Arrhythmia), Lung Disease (COPD, chronic bronchitis, ILD), Kidney disease, Liver disease, or Cancer. *
How often do you engage in de-stressing or relaxing activities (family time, socializing, hobbies)? *
How often do you engage in intense weight-training, body building, running/sprinting, training for marathons or athletic events, or heavy gyming? *
Do you Smoke or Consume tobacco? *
Do you have Alcohol? *
How often do you feel irritated, angry or abusive? *
How often do you feel mentally stressed, anxious, or depressed? *
How do you feel about your general fitness and energy level? *
Do you suffer from digestive complaints like acidity, nausea, constipation, diarrhoea, abdominal pain, belching or bloating (gas)? *
How often have you suffered from fever, cough / cold / sore throat, body pain or severe fatigue in the last 6 months? *
In what range is your body weight considered to be in? *
How will you rate (on a scale of 10 – with 0 being worst and 10 being best), yourself, home and community surroundings on hygiene (cleanliness, access to sunlight/ventilation/fresh air, and presence of pests? *
Do you have family history of Diabetes, Hypertension or Heart Disease (Coronary Artery Disease, Heart attack/Angina/Stroke, Heart Failure)? *
A copy of your responses will be emailed to the address you provided.
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