Health Behaviour Assessment Rate each of the following symptoms based upon your typical health profile for the last 30 days Name * First Name Last Name Email * example@example.com Today's Date - Month - Day Year Date Assessment of Sleep Food Alcohol Movement Continuous Sitting Mind-Body Interventions Targeted Supplements Medications Recent health challenge History of Covid 19 Infection SLEEP How do you rate your sleep * Bad 1 2 3 4 5 6 7 8 9 Excellent 10 1 is Bad, 10 is Excellent On average how many hours do you sleep per night? * Less than 6 hours 6 to 8 hours 8 to 9 hours Longer than 9 hours FOOD I eat according to my plan * Yes No Please respond to this question only if you track your fasting and eating windows. My daily fasting window is Less than 12 hours 12 to 14 hours 14 to 16 hours Longer than 16 hours My first food or drink intake of the day is at * Hour Minutes AM PM AM/PM Option My last food or drink intake of the day is at * Hour Minutes AM PM AM/PM Option ALCOHOL What is one drink? How much alcohol do you drink? I do not drink I drink occasionally Moderate drinking (up to 1 drink per day for women and up to 2 drinks per day for men) Heavy drinking (more than 4 drinks on any day for men or more than 3 drinks for women.) Binge drinking (consuming 5 or more drinks (men), or 4 or more drinks (woman), in about 2 hours. I drink more alcohol now than I did one year ago Yes No MOVE Daily Step Count and Active Minutes I use a wearable device or mobile app to track my daily steps. * Yes No My daily step count is 1000 to 3000 3001 to 6000 6001 to 8000 8001 to 10000 10,000+ Active Minutes Exercise Guidelines recommend that you should get 150-300 minutes of moderate-intensity physical activity or 75 to 150 minutes of vigorous-intensity physical activity every week. As a rough guide, when doing a moderate activity you should be able to talk with others without gasping for air. Do you exercise at moderate intensity for 150-300 minutes every week? * Yes No I do moderate intensity exercise but for less than 150 minutes every week. Do you exercise at vigorous intensity for 150-300 minutes every week? * Yes No I do vigorous intensity exercise but for less than 150 minutes every week. Continuous Sitting Risk I sit continuously for * less than 4 hours per day. 4 to 8 hours per day. 8 to 11 hours per day. More than 11 hours per day. Mind-Body Interventions Mind-body interventions like mindfulness, Tai Chi, Qigong, meditation, and prayers, deep breathing, elicit a Relaxation Response. The Relaxation Response is any technique that causes the following responses: Reduces your heart rate Relaxes your muscles Slows down your breathing Reduces your blood pressure Time spent in Relaxation Response (In minutes) * Targeted Supplements I take the following supplements every day (Please list all) I take the following prescription medications every day (Please list all) Home Blood Pressure Record Checked in the last week Systolic Blood Pressure (Upper number) Diastolic Blood Pressure (Lower number) Pulse Rate Did you experience any major life event in the last few weeks that may impact your health and wellbeing? (Examples: Loss of income, death of loved one, diagnosed with major illness etc.) * Yes No Did you have Covid-19 infection at any time (Mild, moderate or severe) * Yes No Submit Should be Empty: