questionnaire Basic Information Full Name Email Age Gender Male Female Corporate Code Phone Send OTP Section 1: How stressed are you ? Instructions The following questions ask about your feelings and thoughts during THE PAST MONTH. In each question, you will be asked HOW OFTEN you felt or thought a certain way. The best approach is to answer fairly quickly and tell me the answer that in general seems the best. 1. In the past month, how often have you been upset because of something that happened unexpectedly? Never Almost never Sometimes Fairly Often Very Often 2. In the past month, how often have you felt unable to control the important things in your life? Never Almost never Sometimes Fairly Often Very Often 3. In the past month, how often have you felt nervous or stressed? Never Almost never Sometimes Fairly Often Very Often 4. In the past month, how often have you felt confident about your ability to handle personal problems? Never Almost never Sometimes Fairly Often Very Often 5. In the past month, how often have you felt that things were going your way? Never Almost never Sometimes Fairly Often Very Often 6. In the past month, how often have you found that you could not cope with all the things you had to do? Never Almost never Sometimes Fairly Often Very Often 7. In the past month, how often have you been able to control irritations in your life Never Almost never Sometimes Fairly Often Very Often 8. In the past month, how often have you felt that you were on top of things? Never Almost never Sometimes Fairly Often Very Often 9. In the past month, how often have you been angry because of things that happened that were outside of your control? Never Almost never Sometimes Fairly Often Very Often 10. In the past month, how often have you felt that difficulties were piling up so high that you could not overcome them? Never Almost never Sometimes Fairly Often Very Often Section 2: How fit are you ? Do you prefer walking or running test Walking Running Time (In Minutes) to walk 2 kms (max 30 minutes) Section 3: How healthy are you ? Fasting Blood Sugar < 100 100-125 > 125 Resting Heart Rate (beats per minute) 40-60 60-90 90-100 > 100 Oxygen Saturation (SPo2) 95-100 % 90-95 % < 90 % BMI < 18.5 - Underweight 18.5 - 24.9 - Healthy Weight 25.0 - 29.9 - Overweight > 30.0 - Obese Section 4: Lets assess your Lifestyle Do you smoke ? Yes No Whats your alcohol consumption I dont consume alcohol Social drinker 1-2 drinks per week/month Regular Drinker 3-6 drinks per week Habitual drinker > 6 drinks per week Whats your activity level I am a couch potato I workout/walk/run 1-2 times a week I workout/walk/run 3-4 times a week I am a fitness freak and usually dont miss out on exercise Whats your nutrition habits ? I am very inconsistent with my diet or timings I eat usually clean except 2-3 days per week I am very particular about clean eating and timings Section 5: Whats your Sleep Hygiene Score ? Instructions Below you will find a list of statements. Please rate how true each statement is for you. Use the scale to make your choice. Sleep Hygiene Score is an overall indicator of your sleep quality. 1. I take daytime naps lasting two or more hours. Never Rarely Sometimes Frequent Always 2. I go to bed at different times from day to day Never Rarely Sometimes Frequent Always 3. I get out of bed at different times from day to day Never Rarely Sometimes Frequent Always 4. I exercise to the point of sweating within 1 hr of going to bed Never Rarely Sometimes Frequent Always 5. I stay in bed longer than I should two or three times a week Never Rarely Sometimes Frequent Always 6. I use alcohol, tobacco, or caffeine within 4hrs of going to bed or after going to bed Never Rarely Sometimes Frequent Always 7. I do something that may wake me up before bedtime (for example: play video games, use the internet, or clean) Never Rarely Sometimes Frequent Always 8. I go to bed feeling stressed, angry, upset, or nervous Never Rarely Sometimes Frequent Always 9. I use my bed for things other than sleeping or sex (for example: watch television, read, eat, or study) Never Rarely Sometimes Frequent Always 10. I sleep on an uncomfortable bed (for example: poor mattress or pillow, too much or not enough blankets) Never Rarely Sometimes Frequent Always 11. I sleep in an uncomfortable bedroom (for example: too bright, too stuffy, too hot, too cold, or too noisy). Never Rarely Sometimes Frequent Always 12. I do important work before bedtime (for example: pay bills, schedule, or study). Never Rarely Sometimes Frequent Always 13. I think, plan, or worry when I am in bed Never Rarely Sometimes Frequent Always
