Health & Lifestyle Questionnaire
Please fill in the questionnaire below
Name
*
First Name
Last Name
E-mail
Phone Number
*
Format: (000) 000-0000.
Do you feel that you receive balanced nutrition from the foods you eat?
Yes
No
How would you describe your energy levels?
Terrible
1
2
3
4
Amazing
5
1 is Terrible, 5 is Amazing
Would you like to:
Gain weight
Maintain Weight
Lose your belly
Be nice & lean or get ripped
How much would you like to lose/gain?
0-5kgs
5-10kgs
10-15kgs
15-20kgs
20kgs+
Do you exercise?
Not at all
1
2
3
4
Regularly
5
1 is Not at all, 5 is Regularly
Do you have any health concerns?
Diabetes
Heart Disease
Stroke
Obesity
None
Other
Can we call you with more information about the Challenge?
*
Yes
No
Submit
Should be Empty: