1. Do you believe the food you eat effects your health?
*
Yes
No
2. What did you have for breakfast today?
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1. Nothing ⚠
2. Cereal 🍜
3. Porridge 🍲
4. Yoghurt/Fruit 🍏
5. Toast/Pastries 🍞
6. Tea/Coffee ☕
7. Fried/Cooked 🍳
Other
3. How much water do you drink daily?
*
No idea!
2 - 3 Litres
Not enough
3 litres +
4. How active are you on a daily basis?
*
Not at all
Quite active
Relatively inactive
Very active
5.How healthy do you feel?
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1
2
3
4
5
6
7
8
9
10
Not
Very
1 is Not, 10 is Very
6. If you could improve anything, what would it be?
*
Energy
Health
Weight
Fitness
Other
7. Would you like help to achieve your better body goals?
*
Yes
No
A friend might be
Full Name
*
First Name
Last Name
Phone number
*
Mobile number
E-mail
*
Any other info you would like to share:
Current health, goals, reson, time frame etc...
Submit
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