Wellness Questionnaire
A quick questionnaire to find out more about you and your goals; how you feel and how you want to feel. Your answers will help me help you better.
Name
First Name
Last Name
E-mail
Whatsapp Number
-
Area Code
Phone Number
1. How would you rate your daily energy levels?
Little to None. Really a struggle to get through my day without feeling tired.
Good energy in the morning but afternoon slump is a real thing.
Struggle with my mornings but full of energy as day goes on.
I have great energy and don't notice many dips at all.
2. How would you rate your body confidence?
1 - I have no confidence & am unhappy with my body
2
3
4
5 - Feeling confident, feeling great, feeling positive
3. What time do you wake up and what do you have for breakfast?
4. What do you have for lunch?
5. What do you have for dinner?
6. What do you snack on between meals?
7. Do you know how much fibre you eat?
Yes
No
Maybe
8. Do you know how much protein you eat?
Yes
No
Maybe
9. How much water do you drink daily?
1-2 litres
2-3 litres
More than 3 litres
I really struggle with water intake
10. What else do you drink? Juice, fizzy drinks, alcohol, etc. How much of these?
11. How many take away coffees / takeout meals per day/week?
12. How often do you move your body?
1-3 times a week
4-5 times a week
I move my body in some way every day
I don't exercise
13. How much sleep do you get per night on average?
7-8 hours or more
5-7 hours
Less than 5 hours
14. Do you sleep well and wake up energised or tired?
15. How is your digestion? Do you struggle with any of the following?
Bloating
Constipation
Irregular Bowel Movements
Upset Tummy
None of the Above
16. Do you experience cravings? If so, what?
17. What are your health/body/wellness goals? Choose as many as you like
Increased energy
Improved health and better habits
Weight loss
Muscle gain and toning
Better digestion
Stronger immune system
Sports performance
18. What have you tried before to reach your goals? Why didn't it work for you? Please share anything you may feel is relevant
19. Would you be interested in being rewarded for living a healthier lifestyle? Would you like to know more about it?
Yes
No
20. Thank you for sharing with me. Please feel free to provide and further information below and ask any questions.
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