LIFESTYLE SURVEY QUESTIONNAIRE
Thank you for taking the time to answer these questions. Your answers will let us know your wellness score, and your potential risk for developing lifestyle-related disease symptoms.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Male
Female
Weight (in kg)
*
Height (in cm)
*
Age (in years)
*
Waist measurement in cm? (to calculate your body fat zone)
*
What do you eat for breakfast every morning?
*
At what time do you eat your breakfast every day?
*
Please tick all of the applicable feelings/sensations, that you may experience some times
*
Sugar and/or Savory cravings
Constantly feeling hungry before snack/meal times
Energy slumps and fatigue, typically after lunchtime and late afternoon
Lack of focus and concentration
Irritability and/or mood swings
1. Do you eat more meals with lean meats (chicken, red meat, pork), fish and plant proteins (legumes, seeds and nuts), rather than fatty roasts, fried meats or processed meats (sausages, polonies)?
*
Yes
No
2. Do you eat at least 5 servings of veg/salad items/fruit per day, and do you eat them every DAY?
*
Yes
No
3. Do you eat mostly whole wheat products (bread, pasta and brown rice), rather than white bread, pasta and rice?
*
Yes
No
4. Do you eat deep sea/cold water oily fish (salmon, mackerel, tuna, trout, sardines, pilchards) at least 2 - 3 times per week? (NOTE - this does NOT include fish deep friend in oil!!!)
*
No
Yes
5. Is your digestive system regular, and free from constipation, indigestion, heartburn and bloating?
*
Yes
No
6. Have you kept a stable and healthy weight (for your height), mostly, in your adult life?
*
Yes
No
7. Do you usually have enough time to prepare balanced, colourful home-made meals every day, rather than eating on the run, or take-out meals, or pre-packed/boxed meals?
*
Yes
No
8. Do you avoid the following typical snacks - fizzy cold drinks, commercial energy drinks, typical unhealthy snack food (crisps/hot chips/chocolates/sweets/biscuits) every day?
*
Yes
No
9. Are you free from water retention and swelling?
*
No
Yes
10. Do you drink at least 1.5 litres of water per day (woman), or 2l per day (man), and every day?
*
Yes
No
11. Do you have great energy and focus all day long, until bed time?
*
Yes
No
Please submit all your information, and I will prepare your wellness evaluation for you, to provide you with your wellness score (very unhealthy, unhealthy, acceptable, healthy), as well as your BMI and body fat zone. You will be offered the opportunity to work with me as your wellness coach, to change your scores to the healthy zones, as may be applicable.
On completion of your personal wellness evaluation, we will request that you rate our service - valuable, or not valuable - if you rate this service valuable, would you be willing to make our lifestyle survey link available to a few people you know?
*
Yes
No
WHO sent you our lifestyle survey link, or, WHERE did you pick it up from? We must know exactly who communicated with you and provided this survey link. Please provide the full name and telephone number of the person, if it was sent to you by somebody. If not sent by somebody, simply type in where you saw this link.*
*
Phone Number (if from somebody, if not, simply type not applicable)
Submit
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