Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. average Medical exercise, At Mimshack Wellness, our mission is to empower individuals and families to build healthier lives through accessible, high‑quality wellness products that support the body’s natural rhythms and daily needs. As part of this mission, we invite our clients to complete a brief wellness questionnaire at the start of their journey with us. The information collected helps us understand your current health and wellness patterns and allows us to evaluate how our products contribute to your personal wellness goals over time. Your participation is completely voluntary. All information you provide will be kept confidential and used solely for wellness assessment and program improvement. By choosing to participate, you help us better tailor our support and enhance the effectiveness of our wellness offerings. Household and Demographic InformationName *FirstLastHouse Hold Size *Age Group *Under 1818-2425-3435-4445-5455-6465 and overGender *MaleFemaleEmail *Health & Medical History Do you have any chronic health conditions? *Heart diseaseDiabetesHypertensionArthritisAre you currently taking any? *MedicationsSupplementsWhich of these known allergies do you have? *FoodEnvironmentalMedicationHave you had any recent? *SurgeriesInjuriesPhysical limitationsPlease list any specific symptoms you are currently experiencing: Lifestyle & HabitsPrimary Drinking Water Source (Select all that apply) What has been your primary source of drinking water over the past 12 months? *Tap waterWell waterBoreholeRainwaterBottled waterSachetIf your household primarily drinks bottled or sachet water, how much do you typically spend per week (in Naira) on drinking water? Nutrition: On average, how many servings of fruits and vegetables do you consume per day?Describe your typical daily diet:Do you have any dietary restrictions? *YesNoPhysical Activity: How many days per week do you currently exercise, and for how long?Sleep: How many hours of sleep do you average per night? Do you wake up feeling rested? Stress: How do you currently manage stress? On a scale of 1 to 10, your current stress level is: Program Goals & ReadinessWellness Goals & Perceived Health How would you describe your overall health?What are your top wellness goals for the next 6–12 months?What challenges make it difficult for you to maintain healthy habits?Purchase History How did you hear about water ionizer? What model of machine did you buy? *Mimhealth PlusMimhealth UMMimhealth CTWhen did you buy the water ionizer? What are your primary reasons for buying a water ionizer?What improvements do you hope to experience from using our wellness products?Do you currently experience any symptoms or wellness concerns that you would like to track while using alkaline‑hydrogen water? Select all that apply. *Fatigue or low energy — Feeling tired, sluggish, or lacking staminaDigestive discomfort — Bloating, gas, indigestion, irregular bowel movementsHydration challenges — Feeling dehydrated, dry mouth, low water intakeSleep quality concerns — Difficulty falling asleep, staying asleep, or waking unrefreshedStress or tension — Feeling overwhelmed, tense, or mentally fatiguedSkin wellness concerns — Dryness, dullness, breakouts, or irritationHead discomfort — Occasional headaches or head pressureJoint or muscle discomfort — Stiffness, soreness, or general body achesGeneral wellness monitoring — Overall sense of vitality, balance, or wellbeingOthersPlease SpecifyConsent, Participation & WaiverSelect All that Apply *Liability Waiver: I understand that this program is for wellness and educational purposes. I release Mimshack Wellness Koncept Limited from liability for injuries or damages.Confidentiality Agreement: I understand that all information provided will remain confidential.Voluntary participation — Participation in this survey is voluntary. Do you agree to proceed?Data use agreement — Your information will be used only to support your wellness journey and evaluate product impact. Do you consent?Submit
