Wellness Questionnaire Order Number Your Details Tell us about yourself. First Name * Phone or Whatsapp * City * Surname * Email Address * Location * Argentina Armenia Aruba Australia Austria Azerbaijan Belarus Belgium Bolivia Bosnia i Hercegovina Botswana Brazil Bulgaria Cambodia Canada Chile Colombia Costa Rica Croatia Cyprus Czech Republic Denmark Ecuador El Salvador Estonia Finland French Polynesia Georgia Germany Ghana Greece Guatemala Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Kazakhstan Korea Kyrgyzstan Latvia Lebanon Lesotho Lithuania Macau Macedonia Malaysia Malta Mexico Moldova Mongolia Namibia Netherlands New Zealand Nicaragua Norway Panamá Paraguay Perú Philippines Poland Portugal Puerto Rico República Dominicana Romania Russia Serbia Singapore Slovak Republic Slovenia South Africa Spain Swaziland Sweden Switzerland Taiwan Thailand Trinidad & Tobago Turkey Ukraine United Kingdom United States Uruguay Venezuela Zambia Address 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? * NOT AT ALL 03H00 03H30 04H00 04H30 05H00 05H30 06H00 06H30 07H00 07H30 08H00 08H30 09H00 09H30 10H00 10H30 11H00 11H30 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 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? * NOT AT ALL 15H00 15H30 16H00 16H30 17H00 17H30 18H00 18H30 19H00 19H30 20H00 20H30 21H00 21H30 22H00 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 Cellulite Other Nothing 🙂 HEALTH & WELLNESS GOALS Effective HEALTH & WELLNESS GOALS will help maximise your LIFE span, be ENERGISED & ENJOY your Life more too! What are your GOALS? * Increase Energy Lose Body Fat Maintain Healthy Weight Increase Fitness Gain Lean Muscle Eat Healthier Lose Weight Other Why is it important for you to attain these goals? * What other programs / diets have you tried before? How long ago? * 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 Which program/s are you interested in: 6 Day Healthy Breakfast 21 Day Healthy Breakfast 30 Day Challenge (BTC) Healthy Lifestyle Sports Nutrition Who referred you to our Questionnaire? Most convenient time to contact * 8h00-10h00 10h00-12h00 12h00-14h00 14h00-16h00 16h00-18h00 18h00-20h00 How would you like to be contacted * Phone WhatsApp E-mail Who do you know also NEED to complete this Questionnaire to receive a FREE Presentation? (Name/Surname/Mobile no) Name & Surname Mobile no Name & Surname Mobile no Name & Surname Mobile no Name & Surname Mobile no Name & Surname Mobile no Name & Surname Mobile no