Name
*
First Name
Last Name
Email
*
Organization (Company, School or Team)
*
Today's Date
MM
DD
YYYY
Biological Sex
*
Select
Female
Male
Intersex
Prefer not to disclose
Age (Years)
*
Height (cm)
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Weight (kg)
*
Do you have any current or past injuries?
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Low back pain, knee pain, etc.
If yes, what injuries do you have?
Do you have any current or past major health concerns?
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Cardiovascular disease, cancer, diabetes, etc.
If yes, what health concern do you have?
Over the past year, approximately how many days did you miss work due to an illness or health-related concern?
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During the past month, how many hours of sleep have you had per night on average?
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Select
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
During the past month, how often have you had trouble falling asleep?
*
Select
not during the last month (0)
less than once a week (<1)
once or twice a week (1-2)
three or more times a week (3+)
How long (minutes) does it take you to fall asleep?
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Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning and can't fall back asleep?
*
Select
not during the last month (0)
less than once a week (<1)
once or twice a week (1-2)
three or more times a week (3+)
During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
*
Select
not during the last month (0)
less than once a week (<1)
once or twice a week (1-2)
three or more times a week (3+)
During the past month, how often has poor sleep affected your mood?
*
Select
not during the last month (0)
less than once a week (<1)
once or twice a week (1-2)
three or more times a week (3+)
During the past month, how often has poor sleep affected your productivity, your ability to concentrate, or ability to stay awake during the day?
*
Select
not during the last month (0)
less than once a week (<1)
once or twice a week (1-2)
three or more times a week (3+)
During the past month, how tired do you feel 30 minutes after waking up?
*
Select
Not tired at all
Somewhat tired
Moderately tired
Very tired
What type of light activities do you do during the WEEKDAYS?
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Check all that apply.
For a typical WEEKDAY over the past month, how many minutes of moderate activity and exercise (such as jogging, cycling, swimming, yoga, weights/strength training, etc.) did you get?
*
Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
What type of moderate activities do you do during the WEEKDAYS?
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Check all that apply.
For a typical WEEKDAY over the past month, how many minutes of vigorous activity and exercise (such as running, spinning, swimming, hot yoga, weights/strength training, etc.) did you get?
*
Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
What type of vigorous activities do you do during the WEEKDAYS?
*
Check all that apply.
For a typical WEEKEND day over the past month, how many minutes of light activity and exercise (such as walking, easy cycling, gardening, housework, etc.) did you get?
*
Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
What type of light activities do you do during the WEEKEND?
*
Check all that apply.
For a typical WEEKEND day over the past month, how many minutes of moderate activity and exercise (such as jogging, cycling, swimming, yoga, weights/strength training, etc.) did you get?
*
Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
What type of moderate activities do you do during the WEEKEND?
*
Check all that apply.
For a typical WEEKEND day over the past month, how many minutes of vigorous activity and exercise (such as running, spinning, swimming, hot yoga, weights/strength training, etc.) did you get?
*
Select
0
5
10
15
20
25
30
35
40
45
60
75
90
105
120
150
180
210
240
What type of vigorous activities do you do during the WEEKEND?
*
Check all that apply.
During the past month, how much time (hours) do you usually spend sitting on a typical WEEKDAY?
*
Select
0
1
2
3
4
5
6
7
8
9
10
11
12
During the past month, how much time (hours) do you usually spend sitting on a typical WEEKEND day?
*
Select
0
1
2
3
4
5
6
7
8
9
10
11
12
For a typical weekday over the past month, how many meals & snacks did you typically have?
*
Select
1
2
3
4
5
For a typical weekday over the past month, what time did you eat your first meal/snack?
*
Select
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
For a typical weekday over the past month, what time did you eat your second meal/snack?
Select
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
For a typical weekday over the past month, what time did you eat your third meal/snack?
Select
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
For a typical weekday over the past month, what time did you eat your fourth meal/snack?
Select
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
For a typical weekday over the past month, what time did you eat your fifth meal/snack?
Select
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
On a typical weekday over the past month, how many cups of water (or clear liquids with no calories or artificial sweeteners - e.g. herbal tea) did you drink each day?
*
Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Do you have food cravings during the day?
*
Select
Never
Rarely
Sometimes
Often
Always
What kind of foods do you normally crave?
*
Check all that apply.
Tell us about how well you focus during a typical workday.
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I use my time efficiently and effectively.
I am able to focus solely on one task before moving on to the next.
I am able to concentrate on tasks throughout the day.
I am able to block out distractions to focus on a task.
I arrange my schedule so that I can work on my most important tasks during the time of day when I am most alert.
I try to create an optimal environment when I really need to concentrate (e.g. close the door, put up a do-not-disturb sign, turn off notifications, etc.).
I take regular healthy breaks throughout the day (walk, listen to music, meditate, etc.).
When I get into the groove of doing something, almost nothing can get me out of it.
Tell us about your stress levels during a typical workday.
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I often feel that my life consists of a relentless set of demands that I'm expected to meet and tasks I have to complete.
I frequently find myself feeling irritable, impatient, or anxious.
I am often exhausted.
I have frequent arguments with people.
Most of the time I feel I have very little control over my life.
My mind is running so fast I find it hard to concentrate.
I find it hard to leave work at work.
I often work on evenings and weekends and/or I rarely take a tech-free holiday.
What strategies (if any) do you use to cope with stress?
*
Check all that apply.
Tell us about your ability to perform during a typical workday.
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I am confident that I can complete most tasks at a high level.
I am able to meet or exceed the performance expectations I have for myself.
Before beginning a task, I set an approximate time limit as to how long I will work on it.
I prioritize my work to get the most important task done first.
I take time for reflection, strategizing, and thinking creatively.
I am motivated to exercise during the day.
I practice mindfulness/meditation regularly.
I purposely choose healthy foods that will help me perform at my best.
What aspect of your health or performance are you most interested in focusing on or improving?
*
Check all that apply.
Is there anything else you would like us to consider about your health, sleep, physical activity, nutrition, stress, or any other related topic?
