BePure Health Questionnaire

 

The BePure Health Questionnaire asks you to assess how you have been feeling during the last three months.

It is intended to help you begin understanding your personal health story.

How does it work?

The BePure Health Questionnaire will give you a personal snapshot of your current health, identifying where you’re doing well and where you may have need for concern or improvement.

The questionnaire should take no longer than 5 – 10 minutes to complete, but please take all the time you need. Please also note that all information provided is held in strict confidence.

What next?

Once you have completed the questionnaire, we'll email you your results. It is highly recommended you bring these along to the 'What's Your Health Story' event where Ben will walk you through what your results might mean and what you can do about it.

If you have any questions please contact us on 0800 87 37 87 or info@bepure.co.nz

Get Started

Use the below guide to answer each question on your health and wellbeing

No or Rarely
You have never experienced the symptom or the symptom is familiar to you but perceive it as insignificant (monthly or less).

Occasionally
The symptom comes and goes and in your mind, is linked to stress, diet, fatigue. Or some un-identifiable trigger, or it has only occurred to a small degree.

Often
Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it.

Frequently
Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis.

Please enter your details below to begin

PART 1 - Eating right for you and your metabolism

Please indicate to what level you experience the below symptoms

A sense of weakness throughout the day
Feel shaky, jittery or experience trembling hands?
Feel agitated, easily upset or nervous
Frequently need to urinate during the day and night
Eating starchy foods, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight
Find it hard to gain or lose weight

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 2 - Gut Health

Please indicate to what level you experience the below symptoms

Indigestion or food repeats on you after you eat
Excessive burping, belching and/or bloating following meals
Bloating (around your belly button) after eating certain foods
Discomfort, pain or cramps in your colon (lower abdominal area)
Have noticed that your bowel movements change form from eating certain foods
Notice you get tired after eating certain foods
Frequently experience gas production with need for release
Have loose bowel movements

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 3 - Immunity

Please indicate to what level you experience the below symptoms

You often have to clear your throat
Ears ache, itch, feel congested or sore
You catch colds often or more than normal
When you catch a cold, they seem to drag out for you
You experience breathlessness followed by coughing during exertion, no matter how slight
Your eyes, ears, nose, throat and lung symptoms are associated with seasonal changes

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 4 - Liver health

Please indicate to what level you experience the below symptoms

When massaging under your rib cage on your right side, there is pain, tenderness or soreness
Aching muscles, not due to exercise
You are embarrassed by your breath
You have a yellowish cast to your eyes
Tendency to gain weight around your middle or hips and thighs
You wake between 1am and 4am in the morning with a racing mind

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 5 - Inflammation and aches and pains

Please indicate to what level you experience the below symptoms

You experience stiffness in the morning when you wake
Experience joint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)
You have restless legs or muscle tension in legs when lying down
You have difficulty chewing food or your opening mouth
Experience difficulty standing up from a sitting position
You find it difficult to reach up and grab a 5-pound object, like a bag of flour, from just above your head
You injure, strain or sprain easily

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 6 - Energy and fatigue

Please indicate to what level you experience the below symptoms

Experience weight gain for no apparent reason
Your outer third of your eyebrow is thinning
Your body feels sluggish
You have dark bluish or black circles under your eyes
You experience a low in energy levels around 3pm
You struggle to have enough energy to do the things you want to do

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 7 - Mood and mental wellbeing

Please indicate to what level you experience the below symptoms

You describe yourself as feeling miserable and sad, unhappy or blue?
You experience difficulty in decisions and/or clarifying and achieving your goals
You avoid social situations
You consider yourself a nervous person
You do not feel as ‘happy’ as you’d like

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 8 - Heart health

Please indicate to what level you experience the below symptoms

Swelling in feet, ankles and/or legs comes and goes for no apparent reason
You have higher than normal cholesterol levels. Please choose ‘Never’ if you do not know
You have a family history of heart disease
You have a vertical crease in your ear lobe not caused by wearing earrings

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 9 - Nutrients

Please indicate to what level you experience the below symptoms

I eat leafy greens less than 1 time a day
I eat mostly organic food
I eat fast food takeaways more than two times a week
I take nutritional supplements on a daily basis
I consume processed foods daily (white flour, sugar, packaged foods)

SCORE: Please fill in all of the questions in the section above to calculate your score.

PART 10 - Hormone health and balance

Please indicate to what level you experience the below symptoms

Increased anxiety, irritable, depression or restlessness prior to menstruation (select 'never' if you are not menstruating)
Breast tenderness, swelling prior to menstruation (select 'never' if you are not menstruating)
Abdominal bloating, feeling swollen prior to menstruation (e.g. feet) (select 'never' if you are not menstruating)
Temporary weight gain prior to menstruation (select 'never' if you are not menstruating)
Cramping in lower abdomen or pelvic area during menstruation (select 'never' if you are not menstruating)
Your skin, hair and/or eyes feel dryer
Increased weight gain on the hips and thighs
Profuse or prolonged menstrual bleeding (select 'never' if you are not menstruating)
Lower abdominal, back and pelvic pain throughout the month
Sudden hot flashes
You often miss your periods (select 'never' if you are not menstruating)
You use a synthetic hormone contraceptive
You experience menopausal symptoms for longer than 3 months (select ‘no’ if you are not menopausal)

SCORE: Please fill in all of the questions in the section above to calculate your score.

Health and Wellbeing

Please describe your goals

Submit Below to Find out Your Results

Congratulations! Completing the BePure Health Questionnaire is a great first step towards understanding your personal health story. These results will help you take effective, personalised actions towards your long term health and wellbeing.

Simply submit your questionnaire below to receive a detailed breakdown of your scores in each area. Please bring your results along to the What’s Your Health Story seminar where Ben will walk you through what they mean and what you can do to improve them.




This questionnaire has been developed by the BePure nutritional team as a tool to raise general health awareness, and is not designed to diagnose or treat health concerns.

By completing the BePure Health Questionnaire you agree to receive further communications from BePure.

© BePure, 2017. Except as provided by the Copyright Act, no part of this document may be reproduced in any form without the prior written permission of BePure Health Limited.

^

BACK TO TOP