Health

Free Wellness Evaluation

We also offer FREE advice on your health and/or weight problems. Please answer the following questions, so that we can better assist you with your needs. All information you provide is strictly confidential.

Name:
Surname:
Email:
Confirm Email:

Would you or a member of your family like to lose weight?

If so, how much? 3 - 5kg 5 - 10kg 10 - 20kg 20kg & over

Do you have any health problems? Please fill in your problem, how long you have had it & what you have tried.

Do you wake up feeling tired?

Do you suffer from an energy loss during the day?

What is Your Current Weight?

Kgs

What is Your Goal Weight?

Kgs

What is Your Height?

What is Your Age?

Gender

Male Female

What weight-loss programs have you tried?

How serious are you about losing weight?

What is the particular reason you want to lose weight at this time?

How many times a week do you eat out?

Do you exercise at the moment?

How much water do you drink per day?

Litres

Thank you for your responses. Please use the space below for any other information you think would help us to assist you with your weight loss needs.

Comments:

Optional Information - On an average day, what do you eat for:

Breakfast?

Mid-morning Snack?

Lunch?

Mid-afternoon Snack?

Dinner?

Evening Snack?

We may have to contact you with questions regarding your survey or, to fit a program to your needs. Please provide valid information below:

Tel:
Cell:
Fax:
Address: