Wellness Survey

1. Name and surname*

2. What time do you normally go to sleep and wake up?*

3. What do you normally eat for breakfast and how soon after waking up?*

4. What do you have for lunch and how much does that cost? *

5. What do you have for dinner and how much does that cost?*

6. What do you snack on in between and when?*

7. How many cappuccinos or takeouts do you buy per week?*

8. How much fiber do you eat? Do you know?*

9. Are you active? If so, how much?*

10. How many coffees/teas do you drink per day?*

11. How much water do you drink per day?*

12. What else do you drink? Juice/Fizzy drinks/alcohol etc? How much*

13. Do you smoke?*

14. How are your energy levels?
Rate: Very low / OK / Excellent*

15. If you experience fatigue - when do you feel tired?*

16. How is your sleep? Do you wake up feeling energized or tired?*

17. How is your digestion?
Rate: Very bad / Average / Perfect*

18. How is your immune system?
Rate: Very low / Average / Strong*

19. Do you experience cravings?*

20. Would you be interested in VIP pricing for your programme should you decide to try ours? And getting rewarded for getting healthier?*

21. What is your current height? Weight? What is your goal weight?*

22. What is your current clothing size? What is your ultimate clothing size?*

23. What are your health/body goals?
Energy, weight loss, health, toning, better digestion, stronger immune system, muscle gain, sports performance, hair/skin/nails*

24. How do you want to feel?
Energized, fit, string, happy, confident, sexy, calm, less stressed*

25. Preferred method of contact? (Email address or phone number etc)*