YOUR WELLNESS PROFILE
Assessing your current food & lifestyle choices & habits can help you gain insights where you may be falling short and how you can improve it in order to reach your wellness goals. Form only takes 5-10 minutes to complete!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Where are you located?
*
What is your Instagram/Faceboob account?
Best Time to Reach You
*
Morning
Afternoon
Evening
Always
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Your Goals (1 of 2)
What is your age?
*
What is your height?
*
What is your current weight?
*
Please identify your goals. Check 1 to 2 options that apply best
*
HEALTH & WELLNESS: Want to improve your energy levels, get leaner or kick start your Healthy, Active Lifestyle?
WEIGHT MANAGEMENT: Want to lose weight in a healthy & sustainable way and establish a Healthy, Active Lifestyle?
FIT & ACTIVE: Ultimate goal a lean and toned physique? To optimise your diet before, during & after exercise?
TARGETED HEALTH: Improve Digestive Health, Immune Health, Skin Health and/ or Heart Health
If you want lose weight, wow much weight do you want to lose?
What have you tried before? Why did it not work for you?
Why is it important to reach your goals?
*
How would you rate your commitment to reach your goal?
*
1
2
3
4
5
6
7
8
9
10
Low
Best
1 is Low, 10 is Best
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Your Nutrition & Lifestyle (2 of 2)
1. Do Your Have Breakfast Every Morning? *
*
Yes
No
What do you normally have for breakfast?
*
Your Typical Food Choices for Lunch...
*
Your Typical Food Choices for Dinner...
*
Do you snack throughout the day?
*
Yes
No
If yes, what are your regular snacking choices?
*
How much water do you drink during the day?
*
Less than 1 Liter
1 Liter - 2 Liters
More than 2 Liters
What is your level of activity?
Not active (spend most of the day sitting)
Somewhat active (spend a good part of the day on your feet)
Active (spend a good part of the day doing some physical activity)
Where is your energy level during the day?
*
Low
I have up and down
Great, all day long!
What else do you usually consume during the day?
*
Tea
Juice
Soda
Alcohol
Coffee
Energy Drink
Cigarettes
How do you evaluate your eating habits?
*
Great
Good
Bad
Worst
Are you thinking do you need to change?
*
No, I want to continue with my habits
Yes, I'm Ready
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