How would you describe your energy levels this month?
High energy Moderate energy Low energy Fluctuating energy Not sure
Have you been experiencing any physical pain or discomfort?
No pain Mild discomfort Moderate pain Severe pain Occasional pain
Have you been following a balanced diet this month?
Yes, consistently Mostly balanced Occasionally Not really Not at all
Have you engaged in regular physical activity?
Daily exercise Few times a week Occasional workouts Rarely Not this month
Are you actively managing stress levels this month?
Yes, effectively Somewhat Struggling with stress Not focused on stress Not sure
All set, how can we reach you?
Name
Email
Phone
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