Online Wellness Evaluation Form

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Type a question* This field is required.

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E-mail* This field is required.

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Full Name* This field is required.

First Name

Last Name

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Phone Number

Area Code

Phone Number

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Height (feet/inches)

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Weight (Stones and pounds)

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How much weight do you want to LOSE/GAIN or how many clothes size do you want to drop/increase?

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Do you have any other health, fitness or wellness goals? If so, what are the key ones?

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Why do you want to LOSE/GAIN this much?

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What other programmes/products have you tried in the past?

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Why do you feel that these other programme(s) did not work?

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What is your biggest struggle when trying to LOSE/GAIN weight?

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How many times a day do you eat?

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Do you regularly skip breakfast?

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Do you ever have a snack attack? And if so, when... Daytime / Evening

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What is your favourite snack?

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How much do you spend on food per week?

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Where do you carry most of your unwanted weight?

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Do you take vitamins or any type of nutritional supplements currently?

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How many GLASSES of water do you drink daily?

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Do you eat out or have takeaways? How often? (Times/week)

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Where is your energy levels daily, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)

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Do you regularly exercise? If YES, what type and how often?

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What time do you usually wake up?

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BREAKFAST (Eat & Drink)

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AM SNACK (Eat & Drink)

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LUNCH (Eat & Drink)

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PM SNACK (Eat & Drink)

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DINNER (Eat & Drink)

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EVENING (Eat & Drink)

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GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED, ad VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.

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Would you be open to taking a look at how you could make an extra income, whilst improving your health and fitness, without affecting what you're currently doing?

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Who referred you or sent you this survey?

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Would you be happy to share this survey with your friends and family that may have been confiding in you they want to shape or tone up, improve their energy levels or their health in some way, so they might benefit from a Free Wellness Evaluation?

If you have 3 people who you refer, who complete a survey we will be pleased to send you a BONUS of a FREE Bikini Meal & Exercise Plan worth over £25.

If this is something you're open to doing, please send on this survey link explaining what it is. Thank you.