Lifestyle Assessment

Welcome! This form is designed to help us create a Personalized Lifestyle Improvement Tips just for you. Please complete the sections below to share details about your goals, preferences, and current lifestyle. Once you've submitted the form, your customized Personalized Lifestyle Improvement Tips will be sent to you via email. Be sure to check your spam or junk folder, as the email may accidentally land there.

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Email *
Personal Information
First Name *
Age *
Gender *
General Lifestyle
How would you describe your current lifestyle? *
What are your primary goals for improving your lifestyle? (Select all that apply) *
Required
On a scale of 1-10, how satisfied are you with your current lifestyle? *
Physical Health
How many hours of physical activity do you engage in per week? *
What type of physical activity do you enjoy the most? (Select all that apply) *
Required
Do you have any chronic illnesses or conditions affecting your daily life? (Select all that apply) *
Required
How often do you experience physical discomfort or pain? *
Nutrition and Diet
How many meals do you eat per day on average? *
Do you regularly consume fruits and vegetables? *
How often do you eat processed or fast food? *
Are you currently following any specific diet plan? (Optional) *
If you answer Yes in the previous question, specify the diet plan you are currently following? *
Sleep Habits
How many hours of sleep do you typically get per night? *
Do you often feel rested when you wake up? *
Do you have difficulty falling or staying asleep? *
Do you follow a consistent sleep schedule? *
Mental and Emotional Well-being
How often do you feel stressed or overwhelmed? *
Do you engage in activities to help manage stress? (Select all that apply) *
Required
How would you rate your current mood most days? *
Do you have a strong support system (friends, family, mentors) *
Productivity and Routine
Do you maintain a daily or weekly schedule? *
How often do you feel like you manage your time effectively? *
Do you set personal or professional goals for yourself regularly? *
Social Life and Relationships
How often do you spend quality time with loved ones or friends? *
Do you feel satisfied with the level of connection in your relationships? *
How often do you engage in social activities or events? *
Hobbies and Leisure
How much time do you dedicate to hobbies or leisure activities each week? *
Do you feel you have enough time for relaxation and personal interests? *
What activities bring you the most joy or fulfillment? *
Required
Digital and Technology Use
How many hours a day do you spend on digital devices? *
Do you feel your screen time affects your productivity, sleep, or mental health? *
How often do you take breaks from technology or practice digital detox (disconnecting from devices to improve mental well-being and focus)? *
Self-Improvement and Learning
How often do you engage in self-improvement activities? (Activities for Personal Development, Professional Growth, Health and Wellness, Skill Development, Social and Emotional Growth, Financial Improvement, Lifestyle and Environmental Enhancement) *
Do you set aside time for personal growth or learning new skills? *
What are specific areas you'd like to improve in your life? *
Required
Environmental and Financial Well-being
Do you feel your living environment supports a healthy lifestyle? *
Are you satisfied with your financial situation? *
Do you budget or manage your finances regularly? *
Closing Questions
What are the top three things you'd like to change or improve in your life? *
Required
Do you have any barriers or challenges that make it difficult to improve your lifestyle? (Select all that apply) *
Required
Is there anything else you'd like to share that can help us understand your lifestyle better? (Select all that apply) *
Required
Privacy Protection Statement
Your privacy is important to us. The information you provide in this form will be treated with strict confidentiality and used solely for the intended purpose. We will not share your personal data with third parties without your consent, except as required by law. By proceeding, you agree to our privacy policy.  
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