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Section A: Application information

Ethnicity

Section B : Lifestyle Health Assessment – Sleep

What is the quality of your sleep like? [1=Poor, 5=Good]
1 2 3 4 5

How many hours of sleep do you get each night?

Section C : Lifestyle Health Assessment – Nutrition

How would you describe your eating habits? [1=Unhealthy, 5=Healthy]
1 2 3 4 5

How many glasses of water do you have each day?

Describe Your Eating Habbits

Section D : Lifestyle Health Assessment – Other

Weight (KG)

Height (CM)

Body Mass Index (BMI)

Physical Activity
Vigourous Moderate Sedentary

Section E: Happiness Pulse *

We will go through some statements about your feelings and thoughts to help you measure, understand and improve your wellbeing

Overall, how satisfied are you with your life nowadays? (*0=Not at all, 10=Completely)
0 10

Overall, to what extent do you feel the things you do in your life are worthwhile? [1=None of the time, 5=Always]
1 5

I’ve been feeling optimistic about the future [1=None of the time, 5=Always]
1 5

I’ve been feeling useful [1=None of the time, 5=Always]
1 5

I’ve been feeling relaxed [1=None of the time, 5=Always]
1 5

I’ve been dealing with problems well [1=None of the time, 5=Always] *
1 5

I’ve been thinking clearly [1=None of the time, 5=Always] *
1 5

I’ve been able to make my own mind up about things [1=None of the time, 5=Always]
1 5

I have been feeling close to other people [1=None of the time, 5=Always] *
1 5

How often do you spend 30 minutes playing sports or physical exercise? [1=Never, 2=Less than monthly, 3=1-3 times a month, 4=1-2 times a week, 5=Everyday] *
1 2 3 4 5

How often do you spend 15 minutes walking or cycling? [1=Neve, 5=Everyday] *
1 5

How often do you attend courses of some kind? [1=Never, 5=Everyday] *
1 5

How often do you spend time informally learning about something new? [1=Never, 5=Everyday] *
1 5

I notice and appreciate the little things in life. [1=Disagree strongly, 5=Agree strongly]
1 5

I can laugh and see the funny side of things. [1=Disagree strongly, 5=Agree strongly] *
1 5

How often do you meet socially with friends, relatives or work colleagues? [1=Never, 5=Everyday]
1 5

How often do you participate in social activities of a club, society or an association? [1=Never, 5=Everyday] *
1 5

How often do you help out informally with friends or neighbours? [1=Never, 5=Everyday] *
1 5

How often do you get involved in work for voluntary or charitable organisations? [1=Never, 5=Everyday] *
1 5

Do you have a friend or family member with whom you can discuss personal matters? [Yes/No] *
Yes No

I feel like I belong to this neighbourhood. [1=Disagree strongly, 5=Agree strongly] *
1 5

BE Score *

DO Score *

CONNECT Score *

OVERALL Score *

Since Joining Saheli

Since beginning with saheli, Please Describe how your health has improved

Description

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