Name
*
First Name
Last Name
Email
*
City / Town
What Age Group Are You?
18-25
26-35
36-45
46-55
56-65
66 or over
What is your employment status?
Self employed
Work for a salary/wage
Studying
Retired
In between jobs, looking for work
What Industry do you Work in/What Field are you studying?
How would you describe the level of stress in your life?
Healthy level of stress
Unhealthy level of stress - impacting on my mental and physical health
No stress - I go about my life with a great deal of ease
A mixture of stress and ease
Extremely stressed approaching burnout
How would you describe your sleep?
I get 8 or more hours of unbroken sleep each night, and wake up feeling great
I have trouble getting to sleep or staying asleep for longer than 6 hours
My sleep is terrible, and impacting on my health
My sleep is OK
How would you describe your diet? (Pick 1 that best suits))
I eat well at home, not so well at work
I eat whatever I like, comfort food when I feel like it
I eat a meat based diet
I eat a plant based diet
I eat a Low Carb, High Fat diet
I eat a traditional food pyramid diet (high in grains, med protein, low fat)
I try to eat healthy, but could up my game
I'm understand my body well, and fuel it efficiently
I eat whatever is available, including fast food, when I'm hungry
How Many No Alcohol Days Do you have each week?
How Many Days Each Week Do you drink more than three drinks?
Do You Smoke, Or Vape
Neither
Both
Smoke tailor made cigarettes
Smoke tobacco
Vape only
Which of the following activities have you undertaken in the last 12 months
Running more than 3km non stop
Meditation
Growing my own food
Hunting
Fishing
Scuba Diving
Freediving
Yoga , Tai Chi , Qi Gong , Pilates or similar movement
Resistance Training / Gym/ Heavy Lifting
Foraging for plants in nature
A long walk of more than 1 hour in nature
Kayaking
Spiritual study, church
Reading a health or mindset related book
Listening to a health or mindset podcast of 1 hour or more
In your lifetime, have you personally experienced:
Tick as many that apply
Heart problems
Cancer
Stroke
Diabetes
Stress
Mental Health Problems
Acute Mental Health Problems
Food allergies
Vertigo / Loss of Balance
Obesity
Asthma
Back Pain
Arthritis, Hip or Knee Pain
Chronic Fatigue
Which of the following health conditions have you experienced RECENTLY (in the last 2 years)
Tick as many as apply
Heart problems
Cancer
Stroke
Diabetes
Stress
Mental Health Problems
Acute Mental Health Problems
Food allergies
Vertigo / Loss of Balance
Obesity
Asthma
Back pain
Athritis / Hip or Knee Pain
Chronic Fatigue
Please Rate the following statements
I am fitter now than I was 5 years ago
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am more flexible now than I was 5 years ago
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My mental health is better now than it was 5 years ago
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My weight is about right
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have good energy levels
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My destiny is in my own hands
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The future for New Zealand looks prosperous
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am optimistic about the future of the planet
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have the knowledge, wisdom and lifestyle to live a long healthy life
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Good health is in my own hands
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I drink enough good quality water
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Between 60 and 80 I will probably experience some form of chronic illness
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am resilient
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am self sufficient
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
When NZers were asked to get their Covid vaccines did you:
Get 2 shots + booster willingly
Get 2 shots willingly
Get 2 shots + booster unwillingly
Get 2 shots unwillingly
Got 1 shot only, 1st one didn't feel right
No shots - trusted my body to fight it
Are you happy with that choice?
How many times have you visited your doctor in the last year?
How many times have you talked to a therapist or counsellor in the last year?
How many times have you had to visit a hospital (for your own condition) in the last year?
How many times have you picked up prescription drugs for yourself in the last year?
How many times have you talked to a health coach or nutritionist in the last year?
If any of these questions has you wanting more information, help or a chat, leave your contact number here
Family Status - Tick as Many as Apply
Married
In a relationship
Have kids
Divorced
Going through divorce/separation
Blended family
Single
Kids have left home