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    Based on this survey, I will create a personalized nutrition program for you. As part of the cooperation,

    I will give you:

    an individual nutritional plan,

    weekly online consultations,

    support and care from a trainer every day,

    knowledge of how to maintain results independently after achieving a result,

    joining a group on Facebook, where you will receive inspiration and support from people who are in a similar process.

    For those who are willing, a training program and the possibility of additional income to promote a healthy lifestyle are available. Reach out to your coach for more details.

     

    Halina Minkiewicz is your coach

    773-882-1120

     

  • Personal Information

  • Gender*
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Goals

  • Personal Health & Wellness Survey

  • 1.  Do you nap during the day or do you lack energy during the day?*
  • 2. Are you having trouble sleeping?*
  • 3. Would you like to improve your concentration level and reduce the feeling of mental fatigue?*
  • 4. Do you experience headaches and dizziness?*
  • 5. Are you often nervous? Would you like to stress less?*
  • 6. Do you have problems with sinuses, bleeding gums, periodontitis?*
  • 7. Do you have an allergy (food, pollen, skin)?*
  • 8. Are there problems with bones and joints (Rheumatism, osteoporosis)?*
  • 9. You experience pain in muscles, bones and joints (Spine, Knees, hips, legs, hands)?*
  • 10. Does it happen that your limbs swell (hands, feet, legs, arms)?*
  • 11. Do you have cramps / Numbness in your limbs (hands, feet, legs, arms)?*
  • 12. Would you like to improve the condition of your hair and nails (falling out, structure, split ends)?*
  • 13. Do you have skin problems (skin, psoriasis, cellulite, excessive sweating?*
  • 14. Do you have hormonal problems (With the thyroid gland, sugar, pancreas, menstrual cycle, fertility)?*
  • 15. Do you catch a cold more than 1-2 times a year?*
  • 16. Do you have problems with your circulation, blood pressure, cholesterol or triglyceride levels?*
  • 17. You do have problems with the digestive system (Bloating, constipation, diarrhea, ulcers, heartburn, hemorrhoids)?*
  • 18. Do you ever snack between meals?*
  • 19. Are you interested in learning more about proper nutrition?*
  • 20. Are you interested in achieving better sports results (efficiency, strength, speed)?*

  • Your current eating habits

  • 5. Your snacks between meals? (select all that apply)*

  • Your current drinking habbits 

  • 1. How much water will you drink per day?*
  • 2. What other drinks do you drink during the day? (select all that apply)*
  •  -
  • Best day to reach you?*
  • Best time*
  • Please review your data/information before clicking Submit.   
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