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Health and Wellness Questionnaire
Please fill it out as accurately and thoroughly as possible!
Mandatory fields are marked with *
First Name Last Name*
Postcode*
Your email*
Your phone number*
What is your gender?*
Man
Woman
Other
How old are you?*
What is your height?*
What are your goals?*
Weight correction
Feel younger
Look better (skin/hair)
Gain more energy
Help family improve eating habits
Muscle building
Other
What is your current weight?*
What is your target weight?*
When was the last time you reached your target weight?
Why did you decide to take action right now?
Do you have a specific deadline in mind?
Do you have specific issues related to your current weight?
Do you have any digestive issues?*
Are you currently taking any dietary/food supplements? If yes, which ones?*
What is your energy level? Scale from 1 (poor) to 10 (excellent)
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1
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How strongly do you strive to achieve your goal? Scale from 1 (don't care) to 10 (very strongly)
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10
What time do you usually wake up?*
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What time is your 1st meal?*
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What do you usually eat for the 1st meal?*
What time is your 2nd meal?
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What do you usually eat for the 2nd meal?
What time is your 3rd meal?
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What do you usually eat for the 3rd meal?
What time is your 4th meal?
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What do you usually eat for the 4th meal?
What time is your 5th meal?
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What do you usually eat for the 5th meal?
What time do you usually go to bed?*
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How active are you (sports, physical work, etc.)? Scale from 1 (inactive) to 5 (very active)*
How have you found us?*
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