Wellness Evaluation Form
E-mail
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Full Name
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First Name
Last Name
Height (feet/inches)
Weight (Stones and pounds)
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How much weight do you want to LOSE/GAIN or how many clothes size do you want to drop/increase?
Do you have any other health, fitness or wellness goals? If so, what are the key ones?
Why do you want to LOSE/GAIN this much?
What other programmes/products have you tried in the past?
Why do you feel that these other programme(s) did not work?
What is your biggest struggle when trying to LOSE/GAIN weight?
How many times a day do you eat?
Do you regularly skip breakfast?
Do you ever have a snack attack? And if so, when... Daytime / Evening
What is your favourite snack?
How much do you spend on food per week?
Where do you carry most of your unwanted weight?
Do you take vitamins or any type of nutritional supplements currently?
How many GLASSES of water do you drink daily?
Do you eat out or have takeaways? How often? (Times/week)
Where is your energy levels daily, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
Do you regularly exercise? If YES, what type and how often?
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Your Typical Daily Diet
What time do you usually wake up?
BREAKFAST (Eat & Drink)
AM SNACK (Eat & Drink)
LUNCH (Eat & Drink)
PM SNACK (Eat & Drink)
DINNER (Eat & Drink)
EVENING (Eat & Drink)
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GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED and VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.
Would you be open to taking a look at how you could make an extra income, whilst improving your health and fitness, without affecting what you're currently doing?
Who referred you or sent you this survey?
On a scale of 1-10 with 10 being the most serious and committed, how committed are you to changing your current lifestyle habits to achieve your goals?
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