Wellness Questionnaire

 

Gender
MaleFemale

Physical Exercise
YesNo

Sleeping Problems?
YesNo

Dietary Habits
VegetarianNon-Vegetarian

Snacking
RarelyFrequentlyAlways

Hunger Before Meals
RarelyFrequentlyAlways

Drinking Water
0-1 Liters a day1-2 Liters a dayMore than 2 liters a day

Fasting
I have never fastedRarelyFrequently

Alcohol Consumption
I don't drink alcohol0-3 alcoholic drinks per week3-7 alcoholic drinks per week7-15 alcoholic drinks per week

Smoking Tobacco
I don’t use tobacco products1-7 cigarettes a week7-20 cigarettes a week20 or more cigarettes a week

Bowel Movements
0-1 a day1-2 a dayMore than 2 a day

Gas Problems
RarelyFrequently

Allergies?
YesNo

Body Pain?
YesNo

Share This