Coach Nelisiwe Nyoka

Your FREE Health & Wellness Survey

Welcome.

Whether you want to increase your energy, get in to shape, look & feel good, or just improve your health, we can help you!

Complete the Health Survey below, submit it, and we will get back to you within 24 hours.
Hi, I am your coach Nelisiwe.

I used to struggle to get my weight under control. I also used to struggle with fatigue and unhealthy skin. As a family we then discovered the key to a Healthy Active Lifestyle and now we help others to achieve their own health goals. I look forward to helping you get results!
Name*

First NameLast Name
Cell Number*
Where are you from? Town/Province
Whatsapp Number (if different)
Email*
example@example.com
Who is your Coach?
What are your current health goals? (Tick all that apply)*

Weight LossWeight GainMuscle GainIncreased EnergyGeneral HealthSports NutritionSkin Nutrition
What other programs / products have you tried in the past?*
Why do you feel that these other program(s) did not work?*
How are your energy levels during the day?*

TerriblyLowAverageGoodAmazing
What is your breakfast routine like (Tick all that apply).*

Skip BreakfastI eat Cereals or ToastI eat Bacon & EggsOther
How many glasses of water do you drink daily?*
How much do you spend on food daily? *

R25 - R35 per dayR40 - R55 per dayR60 - R80 per dayR85 - R100 per dayR100+ per day
How often do you EAT OUT a week (this includes getting Take-Aways).*

Hardly Ever1 - 2 times3- 4 times
Are you currently taking any prescription medications? If so for what?
Do you suffer from any of the following health issues? (Tick all that apply)

AcneConstipationBloatednessMuscle or Joint PaintFatigueMigraines or HeadachesHeartburnInsomniaPMSUlcersPoor CirculationHigh Blood PressureLow Blood PressureNone
Thank you for completing your form. After submitting the form, I Nelisiwe Nyoka will be in contact with you within 24hrs.
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Hi, I am your coach Nelisiwe.