Wellness Evaluation

1
Name* This field is required.
First Name
Last Name
2
Gender* This field is required.
Female
Male
3
Age* This field is required.
4
Height* This field is required.centimetres
5
Weight* This field is required.kilogram
6
WhatsApp/Mobile Number* This field is required.
Country Code (eg+27)
WhatsApp/Mobile Number
7
Email
example@example.com
Email Verified
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8
In which country do you live in?* This field is required.
9
Do you eat more meals with poultry, lean meat, fish and plant proteins (beans and pulses including soy) rather than steaks, roasts or other red meat?* This field is required.
YESNO
10
Do you eat a variety of colourful fruits and vegetables and do you eat at least 5 servings of these a day?* This field is required.
YESNO
11
Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?* This field is required.
YESNO
12
Do you eat oily fish (such as salmon, mackerel, sardines, trout) at least 3 times a week?* This field is required.
YESNO
13
Is your digestive system free of indigestion or irregularity?* This field is required.
YESNO
14
Do you maintain a stable and appropriate weight?* This field is required.
YESNO
15
Do you usually have time to prepare balanced meals, rather than take-out or eating on the run?* This field is required.
YESNO
16
Do you stay away from fizzy drinks and typical snack foods throughout the day and after dinner?* This field is required.
YESNO
17
Are you free of water retention and bloating?* This field is required.
YESNO
18
Do you drink at least 8 glasses of water a day?* This field is required.
YESNO
19
Is your body free from aching and tired muscles and joints?* This field is required.
YESNO
20
How much do you spend daily on take out foods?* This field is required.Eg. Coffees, fizzy drinks, burgers, pizza, sandwiches, muffins, pastries, sweets etc.
R30 - R60
R60 - R80
R80 - R100
More than R100
I don’t eat take out foods
21
OtherAnything else that you would like to add pertaining to your current lifestyle, illnesses etc?
22
Who can you think about who might benefit from completing this Wellness Evaluation?
23
Name
First Name
Last Name
24
Phone Number
Area Code
Phone Number
25
Name
First Name
Last Name
26
Phone Number
Area Code
Phone Number
27
Name
First Name
Last Name
28
Phone Number
Area Code
Phone Number
Should be Empty: