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

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Email *
Age *
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 / processed / deep fried / junk / 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 (Diabetes, High Blood Pressure, Heart Disease/Coronary Artery Disease/Heart failure, Lung Disease/Asthma/COPD, Kidney/Liver disease, Anemia or Cancer)? *
How often do you engage in de-stressing or relaxing activities (family time, socializing, hobbies)? *
Do you Smoke/Consume tobacco, and/or have Alcohol (>twice/week)? *
How often do you feel irritated, angry or abusive? *
How often do you feel mentally stressed, anxious, or depressed? *
Do you suffer from digestive complaints like acidity, nausea, constipation, diarrhea, 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? *
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)? *
A copy of your responses will be emailed to the address you provided.
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