Let's Get StartedName(Required) First Last Email(Required) ZIP Code(Required) HiddenIs Zip Code Valid? HiddenZIP/Postal Code (Old - Deprecated) ZIP Code Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Birth Gender(Required) Male Female Cell Phone Number(Required) Yes, I would like to opt-in to receive text messages from Aylo HealthAre you married?(Required) Yes No Do you have children?(Required) Yes No When you’re sick do you go to Urgent Care or a Primary Care Physician?(Required) Primary Care Physician Urgent Care Where do you go for Primary Care currently? What is the primary reason you don't go to the doctor?(Required) I don't have insurance I'm not sure where to find a trustworthy doctor It's not convenient Other Do you have health insurance?(Required) Yes No Do you have a Medicare insurance plan?(Required) Yes No Sorry... Your Zip Code doesn't appear to be valid. Please enter a valid Zip Code to continue. Social HealthWhat do you do to calm yourself down when you’re stressed? Choose all that apply:(Required) Watching TV Socializing Drinking Smoking Other How many alcoholic drinks do you have per week?(Required) 0 drinks 1-3 drinks 4-6 drinks 6 or more Do you live alone?(Required) Yes No Which of the following best describes your living situation?(Required) Living with family Living with roommates Living with significant other Living with guardian(s) HiddenSection 1 (Social Health) Score Calculation Physical HealthOn average, how often do you exercise each week?(Required) 0 times per week 1-3 times per week 4-6 times per week Every day of the week What type of exercise do you enjoy?(Required) Strength training Cardio Stretches (yoga, etc.) A mix of cardio and strength training Do you have any long-term injuries?(Required) Yes No Does the injury impact your physical abilities in your daily life?(Required) Yes No HiddenSection 2 (Physical Health) Score Calculation Diet & NutritionHow many meals do you have each day?(Required) 1-3 meals a day 4-5 meals a day 5-6 meals a day 6 or more How would you describe your eating habits?(Required) Intuitive/Energy Eater: Trusting your body to make food choices that feel good for you. Habitual Eater: Eat the same food over and over again, out of habit. Unconscious Eater: Unaware of your food; usually you eat while doing something else. Emotional Eater: Eating as a way to suppress or soothe negative emotions. Do you have any pre-existing conditions?(Required) Yes No Which of the following pre-existing questions apply?(Required) Hypertension Prediabetic Diabetes Type 1 Diabetes Type 2 Sleep Apnea Cancer Low testosterone Other I'd rather not say HiddenSection 3 (Diet & Nutrition) Score Calculation
