Book on longevity – form Name(required) Email(required) Date of birth(required) Gender(required) Male Female Other City of residence with pin code(required) Mobile number(required) How would you describe your fitness and agility levels?(required) What does your normal day look like?(required) What are the 5 tips you will give people to stay healthy?(required) How often do you exercise?(required) Once a week Two – three times a week Three – five times a week More than five times a week I do not get the time to exercise How many times a week do you consume vegetables?(required) Once a day Two - three times a week Five times a week As a garnish to my food almost everyday What is the quantity of vegetables you consume?(required) The regular quantities – a couple of tablespoons once-a-day One vegetable one salad a few times a week One vegetable One salad daily Each of my carbohydrates has garnishing of vegetables so I don't need to take them separately I find it difficult to digest too many vegetables hence take two – three times a week in small quantities One vegetable and one salad daily How often do you eat fruits?(required) One – two times a week Three – five times a week Almost everyday How often do you consume nuts and seeds?(required) Daily Three times a week Four – five times a week Occasionally only What is your height and weight (in kg)?(required) What kind of exercise do you do? Click all that apply.(required) Walking Yoga Gym with weights Swimming/cycling Run/jog Other What are your favourite hobbies?(required) How is your memory?(required) It's good I see a little bit of a decline I have begun to forget things I think my forgetfulness is due to my workload I feel sharper since I changed my diet I need to change my diet to feel sharper Are you a big eater or small eater? If small eater, can you describe portion sizes?(required) How have your relationships been? No word limit(required) Do you have any regrets? Would you like to share them?(required) Name the people who inspire you. They could be writers, philosophers, friends, leaders or loved ones(required) Do you practice deep breathing? (required) Yes No What is your resting pulse rate?(required) Do you drink?(required) Yes No If you drink, what is your choice of alcohol? Whiskey/rum/Scotch/single malt Vodka/gin Red wine White wine Beer How often do you drink?(required) Once a week Two – three times a week Everyday Occasionally I don't drink How many hours do you sleep?(required) Five hours or less Six – seven hours Seven – eight hours Eight hours plus including my afternoon nap Do you take a nap in the afternoon(required) Yes No Are you a vegetarian or non-vegetarian(required) Vegetarian Non-vegetarian Vegetarian but eat eggs If you were to write your mission statement, at this stage of your life, what would it be? (required) I have the following health conditions (click all that apply)(required) High cholesterol High triglycerides Fatty liver Unexplained pain Type 2 diabetes Vertigo Fatigue Thyroid None Hypertension Other If other, please specify(required) Please list all medications you are on, and for what health issues(required) Please list all surgeries you have had, since childhood to now, with age at which surgery was done(required) I confirm that all the above information is medically and legally accurate and can be cross checked and verified.(required) No Yes Submit Δ Share this:Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to print (Opens in new window)Click to email a link to a friend (Opens in new window)Like this:Like Loading...
