.
Health Check
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
Start
Secured
Survio
Create a survey
1
Full name
First and last name
2
Your first and last name
Continue
Create a survey
3
How would you rate your current wellbeing?
How do you feel? How much energy would you say you have?
Continue
Create a survey
4
How much water do you drink a day?
Plain water only, other drinks don’t count into this.
Less than 1 litre
1 - 2 litres
more than 2 litres
Continue
Create a survey
5
How often do you exercise on a weekly basis?
Select one answer
Hardly ever
1 - 2x a week
2 - 3x a week
Daily
Continue
Create a survey
6
Do you consume caffeine to boost your energy or productiveness?
Select one or more answers
Not at all.
Yes - coffee
Yes - energy drinks
Yes - booster fitness drinks
Yes - pills
Continue
Create a survey
7
Do you suffer from headaches or migrane?
Select one or more answers
Yes
No
I know somebody who does
Continue
Create a survey
8
Do you struggle to concentrate and focus?
Select one or more answers
Yes sometimes!
Not at all
I know somebody who does
Continue
Create a survey
9
Do you suffer from joint pain or tense muscles?
Select one or more answers
Yes
No
I know somebody who does
Continue
Create a survey
Continue
Create a survey
Continue
Create a survey
10
Do you suffer from hairloss?
Select one or more answers
Ja
Nein
I know somebody who does
Continue
Create a survey
11
Do you have any issues regarding your scalp such as psora or eczema?
Select one or more answers
Yes
No
I know somebody who does
Continue
Create a survey
Continue
Create a survey
12
Do you suffer from bad digestion?
Select one or more answers
Yes
No
I’m not sure
I know somebody who does
Continue
Create a survey
13
Do you often feel tired or exhausted?
Select one or more answers
Sometimes
Very often
No
I know somebody who does
Continue
Create a survey
14
Do you currently take any supplements to avoid vitamin deficiency?
Select one answer
Yes
No
Continue
Create a survey
15
How often do you get sick per year?
Select one answer
Never
1 - 2x
3 - 4x
More than 5x
Continue
Create a survey
16
Do you have any intolerances or food allergies?
Select one or more answers
Nein
Yes, the following
Continue
Create a survey
17
How would you rate your current diet?
Select one answer
Very healthy!
Quite alright, but could be better!
Unhealthy, I don’t really pay attention to it!
Continue
Create a survey
18
How content are you with your body/weight right now?
Continue
Create a survey
19
How much are you willing to invest in your health on a monthly basis?
Select one answer
Health isn’t that important to me!
50 - 70
70 - 120
120 - 150
150 - 200
More than 200!
Continue
Create a survey
20
On which whatsapp number can I reach you once I’ve analysed your responses?
I’m looking forward to it :) Thanks!
Submit
Create a survey