WELLNESS EVALUATION
Do you feel that you receive balanced nutrition daily from the foods you eat?
Yes
No
Do you eat 3 meals per day?
*
Yes
Sometimes
Never
Do you eat breakfast?
*
Yes
Sometimes
Never
How would you describe your energy levels?
*
Excellent
Ok
Up & down
Lethargic
Would you like to improve your energy levels?
*
Yes
No
Are you satisfied with your WEIGHT?
*
Yes
No
Are you satisfied with your HEALTH?
*
Yes
No
What is your healthy goal?
*
Lose Fat/Tone Up
Gain Healthy Weight
More Energy
Wellbeing
All of above
3. Do you ever participate in sport or exercise?
*
Daily
Weekly
Rarely
Never
Do you Snack?
*
Yes
No
How much water do you drink?
*
Less than a 1L
between 1-1.5L
Over 1.5L
Do you drink coffee
*
Yes
No
How many coffees per day?
Do you drink Alcohol
*
Yes
No
How many times do you drink Alcohol per week?
Have you ever tried any Nutrition programs? If so which ones?
Are you taking any supplements? Which ones?
Are you currently pregnant or breast feeding?
What is your favourite food?
What are your top 3 health goals? Ie. 1. lose weight 2. Gain energy 3. tone up
Would you like to participate in one of the WeDoTransformations 21 day Challenges? Prize money (1k each) for the top 10 best transformations.
On a scale of 1-10 How serious are you about achieving your goal?
*
1
2
3
4
5
6
7
8
9
10
Curious
Very serious
1 is Curious, 10 is Very serious
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Submit
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