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Wellbeing Questionnaire

Wellbeing Questionnaire

Personal Information

Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
Are you currently taking any Supplements?
Do you suffer any of the following
Do you experience any of the following digestive difficulties?
Rate the health of your digestion overall
How often do you have a bowel movement?
Do you experience any food allergies or intolerance?

Fluid and Hydration

Please select what you drink, how often and how much.
plus1 Add a drink minus1 Remove

Food & Diet

What does your diet consist of and how much do you have, please indicate all that apply.
Are you
How often do you cook from scratch?
Do you skip meals?
Do you think you eat for comfort?
How healthy do you consider your diet to be?

Lifestyle

Do you smoke?
How is the quality of your sleep?
How many hours sleep do you get a night?
What time do you go to bed
When you wake up in the morning do you feel well rested and recharged ready for the day?
How often do you exercise?
What forms of exercise do you do and enjoy?
How is your relaxation practice in general?
How many hours a day do you use a screen; computer or mobile device
How many hours a day do you watch TV?
Do you feel tired? How are your energy levels?
Rate your current stress levels

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.