Welcome Form

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 NameLast Name
Email:*
Age*
Height*
Weight*
Waist Measurement (2cm above your belly button)*
Body Fat %age (if known)
MalePrefer not to sayFemale
Occupation
Activity Levels*
Sleep hours per night *
Weight LossEnergyDigestive HealthMood / Brain FogSleepFitnessConfidence in clothesOther
What would success look like to you in the next 3-6 months?*
FatigueCravingsPoor SleepBloatingBrain FogMood SwingsLow MotivationSlow Weight LossWeight GainOther
1-2 times3-4 times5-6 times6+ 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?*
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?*
If you said 'other' please tell us about it*
Please tell us about anything else you want us to be aware of (eg allergies):
1-3 months6-12 months3-6 months12+ months
Why is now the right time for you to look at your health?*
Just curiousSerious but not confidentWaiting for the right timeReally serious and ready to go
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If you answered 'a friend' please write their name here:
e-mailWhatsApp
If you said WhatsApp please provide a number:
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