Wellness Questionnaire
A couple of questions to find out more about you and your goals; how you feel and how you want to feel. Your answers will help me help you better.
Name
*
First Name
Last Name
Email
example@example.com
Whatsapp Number with country code
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Male
Female
Country - please specify province/city
What time do you wake up and what do you eat for breakfast?
What do you have for lunch?
What do you have for dinner?
What do you snack on between meals?
Do you know how much fibre you eat?
Yes
No
Maybe
Do you know how much protein you eat?
Yes
No
Maybe
How much water do you drink daily?
1 - 2 litres
2 - 3 litres
More than 3 litres
I struggle with water intake
What else do you drink? Juice, fizzy drinks, alcohol, etc. How much of these?
How many takeaway coffees/takeout meals per day/week?
How often do you exercise?
1 - 3 times a week
4 - 5 times a week
I move my body in some way every day
I don't exercise
How much sleep do you get per night?
7 - 8 hours
5 - 7 hours
Less than 5 hours
Do you sleep well or do you wake up tired?
How is your digestion? Do you struggle with any of the following?
Bloating
Constipation
Irregular Bowel Movements
Heartburn
None of the above
What are your health/body/wellness goals?
*
Weight Loss + Belly Fat
Gain Healthy Weight + Lean Muscle
Increased Energy
Improved Digestion
Clear Skin
Sports performance
Improved Focus & Concentration
Current Weight
Kg/lbs
Would you be interested in being rewarded for living a healthier lifestyle? Would you like to know more about it?
Yes
No
Thank you for sharing. Please feel free to provide any further details you may feel are important or ask any questions
About Me
I am Phuthi Somo, 39 years old and a mom of 2. Before I started on this program I used to be overweight, lacked energy and suffered from adult acne. I was one of those people who would show up at gym, work hard and not see results and the reason for this was poor nutrition. Everything I ate showed on my face and my body. I have a lost a total of 22kgs and have learnt how to maintain and sustain my healthy body through our incredible nutrition. I now feel and look healthy, I am happier and super excited to help you achieve your body goals! You will receive full coaching and an exceptional body transformation experience from me. I keep it sustainable and affordable according to your budget. Let's walk this journey together.
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