PERSONAL ACCESSMENTFORM

LIFESTYLE WITH KOKO

www.lifestylewithkokouk.com
HealthyTrays Assessment form

Please take your time to read through the questions and give sincere answers.
1. Name*

First NameLast Name
2. Phone Number (WhatsApp Only)*

Area CodePhone Number
3. Email*
example@example.com
MaleFemale
Below 1818 - 3536 - 53Above 53
Healthy eating and lifestyle changeWeight lossWeight gainWeight maintenanceGet control of eating habitsGet strongerHealthy ageingImprove overall healthGet off or decrease medicationsFree phone consultationOther
Please specify if Other
YesNo
8. If yes, which please?*
9. Current weight in kg*
10. Desired weight in kg*
YesNo
12. If yes, what for?
EctomorphMesomorphEndomorphNot sure
PregnantNursingTrying to conceiveNone of the above
15. Do you have any unwanted or unhealthy habits you will like to overcome? (state as many as possible)*
5- Day Detox Challenge (FREE)Waste Flush – 10 Day Body & Mind Detox (£50)62 Day Body Transformation & Habit Change – Group Session (£140)62 Day Body Transformation & Habit Change – Private Session (£200)93-Day Eating to Achieve your Health and Weight Goal – Group Session (£210)93-Day Eating to Achieve your Health and Weight Goal – Private Session (£300)One Off Customized Meal Plan - (£155)None of the above
YesNo
ASAPNot sureIn two weeksNeed consultationOther
WhatsAppE mailPhoneZoomTextOther
20. Disclaimer: The information shared on our programs and website has not been evaluated by NAFDAC, USDA, or any other regulatory agency. It is solely based on our personal experience, studies and rigorous research, which is not aimed to replace any medical advice you may receive from your medical practitioner or health care professional. We assume no responsibility or liability whatsoever on behalf of clients. Please recognise that it is your responsibility to work directly with your health care provider before, during and after seeking health and/or nutrition consultation. If you choose to use this information without consulting with your primary care physician, you agree to accept full responsibility for your decision.*

AgreeDisagree
Disclaimer

The information shared on our programs and website has not been evaluated by NAFDAC, USDA, or any other regulatory agency. It is solely based on our personal experience, studies and rigorous research, which is not aimed to replace any medical advice you may receive from your medical practitioner or health care professional. We assume no responsibility or liability whatsoever on behalf of clients.

Please recognise that it is your responsibility to work directly with your health care provider before, during and after seeking health and/or nutrition consultation. If you choose to use this information without consulting with your primary care physician, you agree to accept full responsibility for your decision.
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LIFESTYLE WITH KOKO

HealthyTrays Assessment form