Wellness Form

Hello, what's your name?* This field is required.

First Name

Last Name

How old are you?* This field is required.

18-25

26-35

36-45

46-55

56+

In which country are you based?* This field is required.

Tell me a bit about yourself? (e.g: I am married with 3 kids and working full-time at a very stressful job)

What is your current job?* This field is required.

Employed Full-Time

Employed Part-Time

Not currently working

Self-Employed

What is your current weight? (in kilograms)* This field is required.

What is Your Height? (in cms)

What is your goal?* This field is required.

Lose Weight

Lose Weight & Adopt a Healthy Lifestyle

Gain more energy

All of the above

If Weight Loss is your goal, how much kilos do you want to lose?* This field is required.(Please select one)

5 Kilo

6-10 Kilo

11-15 Kilo

16-20 Kilo

21-30 Kilo

30 Kilo +

What is your goal weight? (in kilograms)

Why do you want to lose weight? * This field is required.

How do you feel in your current body?* This field is required.

Very Good

Dissatisfied

Okay

Room for improvement

Do you tend to eat more when you stressed out, feeling angry or very busy?* This field is required.

Yes, that happens to me often

No, that hardly happens

Yes, that happens sometimes but not often

How would you rate your eating habits?* This field is required.1-2 Bad, 3-4 Good, 5 Excellent

How would you rate your stress levels?* This field is required.1-2 Bad, 3-4 Good, 5 Excellent

How would you rate your sleeping pattern? (Min 7-8 hours sleep)* This field is required.1-2 Bad, 3-4 Good, 5 Excellent

Do you eat 3 meals a day? (Breakfast, Lunch & Dinner)* This field is required.

YESNO

If not, which meals do you often skip?

Breakfast

Dinner

Lunch

Describe What do you often eat during the day? * This field is required.(e.g: Breakfast: Toasted bread & Tea, Lunch: Chicken Nuggets & Chips with Coke, Dinner: Pizza, Snacks: Chocolate & Cakes etc..)

Do you wake up feeling tired?

Do you have sugar cravings?* This field is required.

When are you most hungry?

How many times during the week do you eat out?

How often do you drink alcohol?* This field is required.

How often do you drink coffee per day?* This field is required.

How Much Water do you drink per day?* This field is required.

500ml

1 Liter

2 Liter

More than 2 Liter

Not Enough

How often do you move your body?* This field is required.

I mostly sit all of the time at work/home without moving my body

I sit and stand most of the time at work/home with movement

I workout at home from time to time

I workout at the gym

I often walk 10 000 steps

Do you have any illness/allergies?* This field is required.

Diabetes

High Blood Pressure

High Cholesterol

Under/Overactive Thyroids

Anemia

Other

None

How much time do you have to cook dinner?* This field is required.

15 Minutes

30 Minutes

45 Minutes

1 hour or more

I don't have time to cook, too tired from work.

What have you tried before? and why did it not work for you?* This field is required.

Are you committed to getting results or just curious?

Do you often give up when you don't see results quickly?

What is your monthly budget for you to achieve your goal?* This field is required.

Are you interested in receiving motivational tips & support on your journey?* This field is required.

YESNO

Email* This field is required.

example@example.com

Phone Number

Please enter a valid phone number.

Signature Required, to confirm. * This field is required.Congratulations on taking the first step. I am confident that I can help you achieve your goal. It is time to get the body of your dreams and feel sexy again.