Lifestyle Survey for High Performing Executives

1. Are you *This question is required.

• Employed
• Self Employed / Business Owner

2. How old are you? *This question is required.

• 18 - 25
• 26 - 35
• 36 - 45
• 46 - 55
• 56 - 65

3. How healthy do you feel? *This question is required.

• Very
• Reasonably
• Not very
• Not sure

4. Do you regularly get colds? *This question is required.

• Yes
• No
• Sometimes

5. On average, how much sleep do you get? *This question is required.

• < 5 hours
• 5 -6 hours
• 6 - 7 hours
• 7 - 8 hours
• > 8 hours

6. Do you wake up feeling refreshed and energised? *This question is required.

• Yes
• No

7. Are you overweight? *This question is required.

• Yes
• No
• Not sure

8. Do you have energy dips during the day? *This question is required.

• Yes
• No
• Sometimes

9. Do you eat breakfast every day? *This question is required.

• Yes
• No

10. Do you think you eat a healthy, well balanced diet? *This question is required.

• Yes
• No
• Sometimes
• Don't know

11. Do you eat ready meals? *This question is required.

• Yes
• No
• Sometimes

12. Do you eat fast food and/or junk food? *This question is required.

• Yes
• No
• Sometimes

13. On average, how much water do you drink daily? *This question is required.

• Not sure
• < 2 glasses
• 3 - 5 glasses
• 6 - 8 glasses

14. How much coffee do you drink daily? *This question is required.

• None
• 1 - 3 cups
• 4 - 6 cups
• 7 + cups

15. On average how much alcohol do you drink a week? *This question is required.

• None
• 1 - 3 glasses
• 4 - 6 glasses
• 7 - 9 glasses
• 10 glasses +

16. How often do you exercise? *This question is required.

• 3 - 5 times a week
• Twice a week
• Once a week
• When I can
• I don't have time

17. What are stress levels like on average at work? *This question is required.1 = low stress 10 = high stress

1	2	3	4	5	6	7	8	9	10
1	2	3	4	5	6	7	8	9	10

18. What are your stress levels like on average at home? *This question is required.1 = low stress 10 = high stress

1	2	3	4	5	6	7	8	9	10
1	2	3	4	5	6	7	8	9	10

19. Do you take regular breaks during the day to restore your energy? *This question is required.

• Yes
• No
• Sometimes

20. Do you often feel distracted at work by things such as email, phone calls, meetings, work colleagues? *This question is required.

• Yes
• No
• Sometimes

21. Do you have time for hobbies, interests or activities you really enjoy? *This question is required.

• Yes
• No
• Sometimes

22. Do you feel satisfied with what you've achieved at the end of a working day? *This question is required.

• Yes
• No
• Sometimes

23. Is your mind continually busy processing "stuff"? *This question is required.

• Sometimes
• Often
• All the time, I find it difficult to switch off

24. How often do you work weekends? *This question is required.

• Never
• Sometimes
• Often

25. Do you regularly take time off to relax and recharge? *This question is required.

• Yes
• No
• Sometimes

26. If you do take time off, is it email and phone free? *This question is required.

• Yes
• No

27. On average, how long is your working day? *This question is required.

• 6 hours or less
• 7 - 8 hours
• 9 - 10 hours
• 11 - 12 hours
• 12 + hours

28. Are there significant gaps between what you say is important in life and how you actually live? *This question is required.

• Yes
• No

29. What are your biggest challenges in your life right now with regard to your health and well being? *This question is required.Tick as applicable

• Energy
• Weight loss
• Image
• Stress
• Time management
• Fitness
• Healthy eating
• Personal brand