WELLNESS EVALUATION/QUESTIONNAIRE

1

Type a questionName and Age:

2

Type a question What Country do you live in:

3

Type a questionWhatsapp number:

4

Type a question1. What time do you wake up and what do you have for breakfast?

5

Type a question2. What do you have for lunch?

6

Type a question3. What do you have for dinner?

7

Type a question4. What do you snack on between meals?

8

Type a question5. Do you know how much fibre you eat?

Yes

No

Maybe

9

Type a question6. How many take away coffees / takeout meals per day/week?

10

Type a question7. How much water do you drink daily?

11

Type a question8. What else do you drink? Juice, fizzy drinks? alcohol? How much of these?

12

Type a question9. Are you active? If so how often and what do you do?

13

Type a question10. How are your energy levels?

Low

Average

Excellent

14

Type a question11. What time do you go to sleep? Do you sleep well and wake up energised or tired?

15

Type a question12. How is your digestion? (indigestion/constipation, bloated etc)

Bad

Average

Excellent

16

Type a question13. Do you experience cravings. If so what? (remember no judgements)

17

Type a question14. What are your health/body/wellness goals? (you can choose as many as you like)

Increased energy

Improved health and better nutrition

Weight loss

Toning

Muscle gain

Better Digestion

Stronger immune system

Sports Performance

Healthy hair/skin/nails

18

Type a question15. Do you feel that you're under-weight or carrying excess weight/out of shape? and what is your goal weight? or neither - happy where I am :)

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Type a question16. What have you tried before to reach your goals? Why didn't it work for you? Please share anything else you may feel relevant?

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Type a question17. Would you be interested in being rewarded for living a healthier and happier lifestyle? Would you like to know more about it?

Yes

No

21

Type a questionThank you for your answers - these will confidential between you and me.