Youth Codes — Wellness Assessment

Section 01

Personal Information & Setup

First Name *

Last Name *

Email Address *

Do you agree to have this assessment recorded?

Yes No

How much time do you have with us today?

Anything important I should know about you before we begin?

Were you able to watch the 2-minute PRISM video?

Yes No Partially

Section 02

Data Protection & Consent

Do you have any questions before we start the assessment?

Section 03

Diet & Daily Routine

How many times do you eat per day?

Servings of fruit per day?

Servings of vegetables per day?

How often do you eat sweets?

Where do you get your fruits and vegetables?

Are you vegan or vegetarian?

Neither Vegetarian Vegan

Protein shakes or protein bars?

Yes No Sometimes

Daily Schedule

Wake up time

Start eating (morning)

Stop eating (evening)

Bedtime

Section 04

Hydration, Fitness & Body Awareness

Water intake per day?

Alcohol consumption?

Do you smoke or use tobacco?

No Yes Occasionally

Daily protein intake?

Do you work out? / Additional sports?

Are you satisfied with your current weight?

Yes No Somewhat

What is your ideal weight goal? (optional)

Are you currently tracking anything health-wise?

Section 05

Work & Lifestyle Context

What do you do for work?

Hours worked per week?

Is your work fulfilling?

Yes Somewhat No

What do you like most about your work?

What do you like least about your work?

Where does your stress come from?

Section 06

Supplement Behaviour

Do you currently take vitamins or supplements?

Yes No Sometimes

What do you take? (list all)

How do you decide what to take?

How do you know if they're working?

Monthly spend on supplements / health products?

Section 07

Health Goals & Concerns

What are your health goals? (select all that apply)

Health concerns you'd like to address:

How important is your health to you? (1 = low · 10 = everything)

7

Not a priorityMy #1 priority

What do you see when you look in the mirror? (face concerns)

Body concerns?

Your top 2 health priorities — and why they matter to you:

Section 08

Family & Investment in Health

Do you have children?

Yes No

Are they living at home?

Yes No N/A

Ages of children (if applicable)

How important is your family's health to you? (1–10)

8

Not a priorityMy #1 priority

Monthly investment you'd consider for your family's health?

How much are you willing to invest daily in your own health?

Section 09

Openness & PRISM

Are you open to solutions beyond what you're currently doing?

Absolutely Possibly Not sure yet

Would you like to learn more about:

The supplement industry Epigenetics Personalised nutrition PRISM technology

What do you think your PRISM score will be?

High (80–100) Medium (50–79) Low (under 50) No idea

Would you like to know the benefits of having PRISM at home?

Yes Maybe No

What did you find most interesting today?

Who would you refer to have this assessment? (names / relationship)

Section 10

Final Reflection

What did you like most about our time together today?

Would you like a follow-up Zoom consultation?

Yes please Maybe No thanks

If products are ordered, would you like an unboxing session?

Yes No

Are you open to discussing building this business together?

Yes, tell me more Maybe later Not interested

Any additional comments or questions?

Wellness Assessment

Thank you, friend.