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Wellness questionnaire

Home / Wellness questionnaire

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TELL US ABOUT YOURSELF

First Name *

Surname *

Email Address *

Phone or Whatsapp *

City *

Location *

Occupation

Children (if so, how many?) *

Current weight (kg) *

Current dress / pants size (cm)? *

Goal weight? *

Married *

No Yes

Birthday *

Waist (cm)? *

Goal dress / pants size (cm)?

What AGE were you when you last were on your Goal Weight/Size?

CURRENT LIFESTYLE HABITS

Effective HEALTH & WELLNESS GOALS will help maximise your LIFE span, be ENERGISED & ENJOY your Life more too!

What TIME do you normally Wake Up? *

How do you feel when you wake up? *

Tired Refreshed Other

At what TIME do you have BREAKFAST? *

What do you usually have for breakfast? *

If you SKIP Breakfast, give reason(s) WHY *

Not hungry

No time

Not important

Other

What do you usually have for lunch? *

What do you drink throughout the day? *

Nothing

Coffee

Fruit juices

Energy drinks

Tea

Fizzy drinks

Water

Other

How much water do you drink per day?

What do you snack on during the DAY/WEEK? *

How do you generally feel during the day? *

Energy dip

Hungry

Low / No Concentration

Cravings for Sweet/Salt

Other

What do you normally have for DINNER? *

At what time? *

What do you snack on in the EVENING? *

How do you SLEEP at night? *

Well Interrupted Not Well

What do you do to RELAX? *

Do you EXERCISE? (What kind)? *

How many times per week? *

Do you struggle with? *

Stress

Constipation

Bad Skin

Headaches

Nothing 🙂

Cellulite

Other

If other, please specify:

HEALTH & WELLNESS GOALS
Effective HEALTH & WELLNESS GOALS will help maximise your LIFE span, be ENERGISED & ENJOY your Life more too!

What are you interested in?

Healthy Breakfast

Healthy Lifestyle

Weight & Fatloss

Muscle gain

Sports Performance

Increase energy

Digestive health

Immune Health

Healthy Ageing

Vegan friendly, Lactose and Gluten Free diet

Skin nutrition

What are your goals and by when would you like to achieve it?

Rate your CURRENT Health & Wellness (1 = Bad; 10 = Excellent) *

0 1 2 3 4 5 6 7 8 9 10

How SERIOUS are you to achieve your goals (1 = Not so Serious; 10 = Extremely Serious) *

0 1 2 3 4 5 6 7 8 9 10

FusionFitMom

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