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Surveys
2012
August
D
Daily Life Style Survey
Daily Life Style Survey
0%
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Do you think breakfast is important?
Very Important
Important
Fairly Important
Not Important
What do you usually take for your breakfast?
Rice/Noodles
Bread/Biscuits
Coffee/Tea/Plain Water
Oats
Other
Do you skip breakfast sometimes?
No, I never skip.
Yes, sometimes I do.
Do you think that exercise is important?
Very Important
Important
Fairly Important
Not Important
What kind of exercise you are doing?
Gym
Yoga
Jogging
Sports (badminton, football, tennis etc)
Swimming
Other
How many times you exercise in a week?
1-2 times per week
3-4 times per week
5-7 times per week
Have you done any medical check up or blood test this year?
Yes
No
Do you have the following concerns?
Uric Acid
High Colesterol
Hypertension
Diabetics
Allergy
Underweight
Overweight
Lack of Energy
Other
Contact Information
*
First Name
:
*
Last Name
:
Address 1
:
Address 2
:
City
:
State
:
Zip
:
*
Phone
:
*
Email Address
:
Daily Lifestyle Survey
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