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Health and Energy Questionnaire
Health and Energy Questionnaire
Health and Energy Questionnaire
If you are human, leave this field blank.
Name
*
Date
*
Phone Number
*
Email
*
Health
Tired most of the time
*
1
2
3
4
5
Overweight
1
2
3
4
5
Prone to hormonal symptoms
1
2
3
4
5
Suffering from poor memory or concentration
1
2
3
4
5
Low or depressed
1
2
3
4
5
Plagued by dry skin or need of daily moisturisers
1
2
3
4
5
Having difficulty sleeping
1
2
3
4
5
Often feel anxious or stressed
1
2
3
4
5
Prone to indigestion or bloating after food
1
2
3
4
5
Often constipated (you rarely go twice a day)
1
2
3
4
5
Suffering from dark circles or bags under your eyes
1
2
3
4
5
Energy & Blood Sugar Control
I still feel tired 20 minutes after getting up
1
2
3
4
5
I need tea, coffee or a cigarette, or something sweet to get me going in the morning
1
2
3
4
5
I often crave chocolate, sweet foods, bread , cereal or pasta
1
2
3
4
5
I often have energy slumps during the day or after meals
1
2
3
4
5
I often crave something sweet / coffee after meals
1
2
3
4
5
I often have mood swings or difficulty concentrating
1
2
3
4
5
I get up dizzy or irritable if I go 4 to 6 hours without food
1
2
3
4
5
I often overreact to stress
1
2
3
4
5
I have less energy than I used to
1
2
3
4
5
I often feel too tired to exercise
1
2
3
4
5
I am gaining weight/finding it harder to lose weight.
1
2
3
4
5
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