Wellness Questionnaire 2026
Please complete the questions below so that I can help you with your health and wellness goals.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 000 000 0000.
Email
*
example@example.com
Meals & Snacks
What do you have for breakfast?
*
What does your average lunch look like?
*
What do you generally have for dinner?
*
What do you snack on during the day and after meals?
Liquid Intake
How much water do you drink daily?
*
Less that 1 litre
1 to 2 litres
More than 2 litres
Sleep, Energy & Exercise
How many hours do you sleep at night?
*
Describe your average quality of sleep.
*
Poor
Average
Good
How do you rate your energy?
*
Little to none
Good in the morning with afternoon slumps
Tired in the morning, but better as the day goes on
Great energy all day
Exhausted by dinner time - fall asleep in front of TV
Do you exercise and how many hours a week?
*
No exercise
Less than 2 hours a week
2 to 4 hours a week
More than 4 hours a week
Eating & Nutiriton
How many meals do you have a day?
*
Breakfast
Lunch
Supper
Do you have cravings? If so, let me know what they are.
*
General & Goals
Do you struggle with any of the following?
Digestive issues (bloating, constipation, diarrhoea, irregular etc.)
Low immune system
Overweight
Underweight
Skin / hair health issues
What are your goals? Tick as many as you like.
*
Better energy / mood
Better health
Lead a helathier more active lifstyle
Feel less stressed
Improved sports performance
Improved mental focus
Heart health
Anti aging
Improved daily nutrition
Family nutrition
Do you have a Wellness Coach?
*
Yes
No
Would you like to join a 5 day wellness coaching experience as a trial to me helping you?
Yes please
More info please
I will be in contact with you to run through the results with you and to advise and help you accordingly once I've received your questionnaire.
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