Welcome Form
Please help us save time at - and prepare for - your Wellness Snapshot by completing this form at least 2 days before your appointment. Your answers are safe with us.
Name
*
First Name
Last Name
Email:
*
Age
*
Height
*
Weight
*
Waist Measurement (2cm above your belly button)
*
Body Fat %age (if known)
Gender
Male
Prefer not to say
Female
Occupation
Activity Levels
*
Please Select
Limited activity - I try and walk when I can
Medium Activity - I walk and do 1 planned workout a week
Active - I do 2-5 workouts a week including walking
Sleep hours per night
*
Please Select
3- 5 hrs
6-7hrs
8+ hrs
What would you most like to improve?
*
Weight Loss
Energy
Digestive Health
Mood / Brain Fog
Sleep
Fitness
Confidence in clothes
Other
What would success look like to you in the next 3-6 months?
*
Tick all your current symptoms
*
Fatigue
Cravings
Poor Sleep
Bloating
Brain Fog
Mood Swings
Low Motivation
Slow Weight Loss
Weight Gain
Other
How often do you eat during the day?
*
1-2 times
3-4 times
5-6 times
6+ times
How much water do you drink each day ( a cup is 250ml)?
*
How much coffee do you drink each day ( a mug is 250ml)?
*
How much alcohol do you drink each day ( a glass of wine is 125ml)?
*
How do you feel about exercise?
*
Breakfast - What time do you eat it and what do you usually eat?
*
Lunch - What time do you eat it and what do you usually eat?
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Dinner - What time do you eat it and what do you usually eat?
*
Snacks - Do you have mid morning, mid afternoon or after dinner snacks? When do you snack and what do you usually snack on?
*
What have you tried before to lose weight?
*
Please Select
Slimming World
Weight Watchers
Keto
Low Carb Diet
Diets like the cabbage Diet
Paleo
Meal Replacement Shakes
Personal Trainer
Gym Membership
Calorie tracking Apps
Other
If you said 'other' please tell us about it
*
Please tell us about anything else you want us to be aware of (eg allergies):
How quickly do you expect to reach your goals?
*
1-3 months
6-12 months
3-6 months
12+ months
Why is now the right time for you to look at your health?
*
How serious are you about addressing these concerns and reaching your goals?
*
Just curious
Serious but not confident
Waiting for the right time
Really serious and ready to go
Where did you hear about us
*
Instagram
Facebook
Google Search
A friend
If you answered 'a friend' please write their name here:
How would you like us to contact you?
e-mail
WhatsApp
If you said WhatsApp please provide a number:
Submit
Should be Empty: