Free Health Assessment - The Project Reversal

Email Address

Full Name

Age

Height (in cm)

Current Weight (in kg)

Waist Circumference (in cm)

City & Country

Have you been diagnosed with any of the following?

If other condition, please specify

Are you currently taking any prescription medication?

Yes
No

If yes — list your medications (name + dosage + condition)

Do you have recent blood reports?

Yes — within last 3 months
Yes — within last 6 months
No

Have you ever had surgery?

Yes
No

If yes — describe surgery and approximate year

Have you been hospitalised in the last 2 years?

Yes
No

If yes — reason for hospitalisation

Do you have any known allergies?

Yes — food allergies
Yes — medication allergies
Yes — environmental allergies
No known allergies

If yes — please specify your allergies

Do you have any physical limitations or injuries?

Yes
No

If yes — describe the limitation or injury

Have you been told by a doctor to avoid any specific exercise or diet?

Yes
No

If yes — what to avoid

Are you taking any supplements or OTC medication?

Yes
No

If yes — list your supplements

Have you taken weight loss medication or supplements in the past?

Yes
No

Do you smoke or use tobacco?

What Do Female)

If you smoke — cigarettes per day?

Do you consume alcohol?

If you drink — what do you typically consume?

Do you consume recreational substances?

No
Occasionally
Prefer not to say

Cups of tea or coffee per day?

None
1-2 cups
3-4 cups
5 or more cups

Glasses of water per day?

Less than 4 glasses
4-6 glasses
7-8 glasses
More than 8 glasses

Hours per day on screens (phone/laptop)?

Less than 3 hours
3-5 hours
6-8 hours
More than 8 hours

Do any immediate family members have the following?

What is your occupation?

How would you describe your daily activity level?

Mostly sitting (desk job / minimal movement)
Moderately active (some walking / light activity)
Very active (physical job / regular movement)

How many hours per day do you sit on average?

Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours

Do you currently exercise?

Yes — regularly
Occasionally
Rarely
Not at all

What type of exercise do you do?

How many days per week do you exercise?

0 days
1-2 days
3-4 days
5 or more days

What best describes your diet?

Vegetarian
Eggetarian
Non-vegetarian
Vegan

How many meals do you eat per day?

1-2 meals
3 meals
4 or more meals
Irregular / no fixed pattern

Do you frequently consume any of the following?

How many hours do you sleep on average per night?

Do you experience any of the following digestive issues regularly?

Gender

Male
Female
Prefer not to say

(For Male) Do you experience any of the following?

(For Male) Have you ever had your testosterone levels tested?

Yes — levels were normal
Yes — levels were low
No — never tested

(For Female) Are your menstrual cycles regular?

Yes — regular (every 28-35 days)
No — irregular cycles
Cycles have stopped (menopause / other)

(For Female) Have you been diagnosed with PCOS or hormonal imbalance?

Yes — diagnosed
Suspected but not yet diagnosed
No

(For Female) Do you experience any of the following?

What is your primary health goal?

Improve blood sugar / reverse diabetes
Weight loss / fat reduction
Hormonal balance (PCOS / thyroid)
Improve energy and reduce fatigue
Manage blood pressure / cholesterol
Overall lifestyle improvement

What has stopped you from improving your health so far?

Why do you want to join Project Reversal?