Fitness and Health Survey
How would you describe your energy levels
UP & Down
Lethargic
Ok
Excellent
Would you like to improve your energy levels
Please Select
Yes
No
Comments
Do you exercise?
Not at All
1-2 days a week
3-4 days a week
5-6 days a week
Everyday
Spasmodically
What exercise do you do?
Walk
Running
Gym
Swim
Golf
Team Sports
Cycling
Other
Would you like to improve your sports performance, fitness, and stamina?
Please Select
Yes
No
Do you suffer from health complaints? eg. colds. flu, allergies, diabetes, blood pressure, etc. Please list them plus any medicines
Do you feel that you receive balanced nutrition daily form the foods you eat?
Please Select
Yes
No
Would you like to
Gain weight
Lose weight
Reshape
Trim body fat
Other
How much would you like to fain/trim to achieve your ideal weight?
Less than 5 kgs
5-10 kgs
10-20 kgs
20-30 kgs
30+
Other
If there was a way you could lose/gain/maintain your weight and still eat the foods you love and improve energy levels, sports performance or other health issues would you be in a FREE wellness consultation?
Please Select
Yes
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please enter the word in the box for security
*
Submit
Should be Empty: