Full Name Mobile
Email Address
Suburb Pincode
Date Of Birth (dd/mm/yyyy) Residence Phone No.
Organization Designation
Height in ft/inches Weight in Kgs

Rest & Sleep

How many hours do you sleep in a day

Teenagers 9-10 hrs, Adult 7-8 hrs, Pregnant > 8 hrs
Teenagers 7-9 hrs, Adult 5-7 hrs, Pregnant 6-8 hrs
Teenagers < 7 hrs, Adult < 5 hrs, Pregnant < 6 hrs
Remarks :

Do you have breaks in sleep

Yes my sleep is disturbed
Remarks :

How do you feel throughout the day

Always Fresh
Some part of the day lethargic
Somewhat lethargic
Remarks :

Do you have any nap or relaxation during the day

Yes everyday some relaxation of less than 30 mts
Yes everyday more than 30 mts
Some days
No I do not have any relaxation during the day
Remarks :

Do you feel fresh after waking up

Yes always
Sometimes feel lethargic
Always feel not slept enough
Remarks :


Do have regular vacations [tick whichever applicable, may be more than 1 or none]

Yes every year at least 7 days
Normally with family
Have another 7 day vacation in a year
Also small trips every quarter
Remarks :

Organized Lifestyle

Do you find yourself quickly reacting to things or responding

I absorb and then respond
Sometimes I react
Normally I am reactive
Remarks :

Are you optimistic

Yes Optimistic
Sometimes optimistic
Sometimes pessimistic
No normally pessimistic
Remarks :

Is your workday planned

Yes and I normally follow
I plan sometimes but cannot always follow
I dont plan my day in any way
Remarks :

How do you relate with others

Normally I find myself contributing to others life
I believe in give and take
I expect to get from wherever I feel I deserve
Remarks :

Financial Responsibility

Facts about your financial responsibility [tick wherever applicable, may be more than 1 or none]

I have inherited financial security
I have already provided enough for my future
I feel capable of providing for my future
We are a double income family
Remarks :


Do you meditate

I don't meditate
Yes I regularly meditate
I schedule to meditate but manage less than 4 times a week
I meditate less than once a week
Remarks :

Do you feel peace/bliss/serneity during the day

Yes always
Some parts of the day are disturbed
No I am not familiar with these things
Remarks :

Do you think you are creative/innovative

Yes always
No I dont belong to that category
Remarks :


Do you have strong Likes & Dislikes or opinions causing strong arguments

No normally not
Remarks :

Do you tend to carry your Ego ?

Never, I am generally aware of my Ego and do not allow it come in
Remarks :

Are you anxiety prone ?

Many times
Never, I am generally cool
Remarks :

Do you feel depressed ?

Yes often
Never, I have healthy recreation activites
Remarks :

Are you often Angry ?

Usually happy state of mind
Remarks :

Eating Habits

How many meals do you have in a day

5 to 6 meals - Breakfast, Lunch, Snacks, Light Dinner and extra intermittent 1-2
3 to 4 meals - Breakfast, Lunch, Dinner and sometimes snacks
1 to 2 meals - Lunch/Brunch and Dinner
Remarks :

How healthy is your diet ?

At least 10 glasses of water
No or rare consumption soft drinks
Good amount of Proteins like Eggs/ Soya / Chicken / Cow milk Paneer / Protein supplement
Do not sleep for 2 hours after dinner
No Junk food
Do not drink water with meals
No munching between meals
Remarks :

Active Lifestyle

Do you exercise in any form daily ? How many times ?

Yes everyday or 6 times a week
At least 3-4 times a week
once a week
Never or irregular
Remarks :

Do you walk apart from the exercise daily ?

Yes daily 30 mts
Yes anywhere between 15-30 minutes, or sometimes
No generally not
Remarks :

How do you describe your work life ?

Sedentary Office or Home
Mild activity at work or home
Active, walking and other physical activities
Varying - sometimes sedentary sometimes active
Remarks :

Do you have active hobbies ? How much time do you spend on it ? [minutes]

Daily more than 30 min
Sometimes less than 30 min
Never, do not get time
Remarks :

Addictions in Lifestyle

Do you smoke? If yes, how many cigarettes in a day ?

Never smoked
More than 5
Remarks :

Do you consume alcohol? If yes, how often ?

Once in 3 months
Once in a month
Twice a month
More frequent than once a week
Remarks :

Are you addicted to anything apart from this ? [mention even if it may be as trivial or what you feel harmless as eating sweet..]

Yes - mentioned below
Remarks :
Follow Up Date (dd/mm/yyyy) Grand Total