FREE Wellness Consultation
Questions marked by * are required.
1.	Name: *
2.	Email: *
3.	Would you like to lose weight, gain weight or improve your health? * Lose Gain Improve health
4.	Height *
5.	Weight in kgs / lbs. (pls state) *
6.	How would you rate your diet? * Balanced Fast Fat Free Very Healthy Vegan Vegetarian
7.	Do you get at least 30min exercise at least 3 times a week? * Yes No
8.	How would you rate your energy levels? * Good Average Low
9.	Do you eat oily fish or take Omega fatty acid supplements? * Yes No
10.	Do you snack during the day? If so, what do you snack on? *
11.	Do you experience water retention / bloating? * Yes No
12.	Do you drink at least 8 glasses of water every day? * Yes No Sometimes
13.	Do you skip meals? * Yes No
14.	Do you have any of the following conditions? (Select all that apply) * Anemia Heart Conditions Depression Pain Erectile Dysfunction Joint Problems Digestive Conditions Low Immune System Other
15.	Do you actively participate in sports? * Yes No
16.	Are you a smoker? * Yes No
17.	Anything else we should know about your health? *
18.	On a scale from 1-10 (10 being the most serious) how serious are you about losing weight? *
19.	Which of these statements do you agree with? * I know that it will take time / effort / money to lose weight I am not prepared to go to gym / pay money / change my lifestyle to lose weight I am prepared to make some investment in my health
20.	Would you like a coach to cheer you on while you lose your weight? * Yes No
21.	If you have been looking at different programs, how much would you have to spend on average for a monthly program? *
22.	How would you like to get it for 25% less once you have achieved a result? * Very much! I wouldn't like it