Welcome to the Brain Potential Wellness Check Questionnaire

For all statements, please choose a number between 1 and 5 where

1 = Strongly Disagree

2 = Somewhat Disagree

3 = Neutral

4 = Somewhat Agree

5 = Strongly Agree

Type a number between 1 and 5 in each box

I get between 6-8 hours of quality sleep a night *

I have a regular bedtime routine on most nights *

If I wake during the night, I find it easy to get back to sleep *

Upon waking, I feel refreshed *

Type a number between 1 and 5 in each box

I mostly eat fresh, unprocessed food *

I avoid fast food outlets and eat minimal takeaways *

I serve myself small portion sizes rather than overeating *

I feel satisfied after eating rather than bloated *

I drink at least 1-2 litres of water a day *

When I eat, I eat slowly to enjoy the flavour of the food *

Type a number between 1 and 5 in each box

I exercise at least 3-4 times per week *

I enjoy the exercise that I do *

My mind and body feel the benefit of exercise *

I regularly take time to move around during the day *

I feel uncomfortable if I miss out on exercising *

Type a number between 1 and 5 in each box

I find it easy to relax my body and brain each day *

I enjoy listening to mindfulness apps *

I try and give myself some space to relax during a busy day *

I enjoy meditating *

I can regain a sense of calm after being stressed *

Congratulations on completing the questionnaire.

Please complete your details below and we will email your results to you.

First Name *

Email *