What is your age group *

How often do you feel stressed or anxious *

Rarely or never

Sometimes

Often

Almost always

How often do you engage in physical activity even walking *

5+ times/week

3–4 times/week

1–2 times/week

I don’t exercise

Do you prioritize sleep and recovery *

Yes, consistently

I try, but life gets in the way

I’m usually tired or sleep-deprived

Sleep is not a priority

How do you manage mental health struggles like anxiety or stress *

I use therapy or mental health tools

I talk to trusted people

I try to deal with it alone

I avoid thinking about it

How do you feel about your body *

I feel confident and healthy

Neutral

Often self-critical

I struggle with how I look/feel

What best describes your emotional state recently *

Balanced and calm

Up and down

Emotionally unstable

Overwhelmed or numb

How healthy is your diet and nutrition *

Very healthy

Somewhat healthy

I often eat what’s convenient

I don’t focus on nutrition at all

Are you comfortable discussing health issues *

Very open

Only with close people

I usually keep it private

I avoid talking about health

How often do you experience physical symptoms like pain, fatigue, or discomfort *

Rarely

Occasionally

Frequently

Almost daily

Are you actively working on your mental and physical health *

Yes, both consistently

I focus on one more than the other

Occasionally

Not at all

Have you ever self-diagnosed a mental health condition like anxiety, ADHD, etc *

Yes, and I’ve confirmed it with a professional

Yes, but haven’t talked to anyone

I suspect something but not sure what

I haven’t thought about it / avoid labels

Which of these statements best describes your experience *

I have a diagnosis and follow a plan

I notice patterns but haven’t explored them

I often self-diagnose based on symptoms

I feel off but ignore it

Which of these do you relate to the most *

I’ve worked through past trauma or mental health issues

I suspect I have ADHD, OCD, or anxiety

I feel physical symptoms without clear cause

I just feel "off" all the time

How connected are your mind and body *

I actively keep them in sync

Mental stress affects my body

My body shuts down under emotional stress

I feel totally disconnected

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First Name *

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