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Health & Lifestyle Questionnaire
This wellness form takes 1 minute to complete. I'm looking forward to learning more about you and your goals! Best, Tal x
Your Details
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram Name @
Where are you based? (Country)
*
What appeals to you the most? (select those that apply)
*
Weight Loss / Getting Leaner
Sports Performance
Build Muscle
Energy and Vitality/ Healthier Lifestyle
How serious are you about achieving your health goal from 1-10?
*
Please Select
1
2
3
4
5
6
7
8
9
10
(1 being far, 10 being close)
How far do you feel you currently are from your ideal health/body shape from 1-10?
*
Please Select
1
2
3
4
5
6
7
8
9
10
(1 being far, 10 being close)
What do you typically have for breakfast each day? (add examples or add nothing if you skip breakfast)
*
How many times do you usually eat per day?
Do you drink more than 2 litres of water on a daily basis?
Yes
No
Do you exercise on a regular basis?
*
Relatively inactive (0-1 time per week)
Somewhat active (2-3 times per week)
Very active (4-5 times per week+)
Do you know your daily protein target and why this is important?
*
Yes
No/I'm not sure
What is the thing you struggle with, or find the most difficult, when it comes to leading a healthy lifestyle?
For example: Lack of education on nutrition, Comfort eating / Snacking, Lack of motivation/consistency, Staying accountable on your journey(Or all of these)
Who do you know who also struggles with the same things? (if anyone)
How would you explain your current mindset?
Very Happy in all areas of life
Reasonably Happy and content
Somewhat Unsatisfied with certain elements of my life
Very Stressed
What do you find bring you the most Stress in your life?
Lack of Body Confidence
Unhealthy Lifestyle
Financial Pressures
Never Enough Time
Out of the following options, what appeals to you most?
Work on my physical health results
Be a part of a positive community
Have more time & less financial stress
Work on my physical health, create an additional & be part of a positive community
Would you be open to watching a short video on how we can help you achieve your goals with accountability and support by joining one of our 10-day focus groups?
Yes please!
More information
Maybe in the future
Type the name of the person who sent you this form?
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