Personal Wellness Evaluation

Complete the form below for your free Personal Wellness Evaluation
(Your Privacy is very important to us and your details will never be shared)

 Please provide your name
Name
 Please provide your email address
Email
Address
City/Town
Postcode
 Please provide your phone number
Phone
 What is your height in cm?
Height (cm)
 What is your weight in kg?
Weight (kg)
 How young are you?
Age
 Please give a brief description
What are your reasons for having a wellness evaluation today?
 Please provide an answer
Do you eat more chicken, fish & lean meat rather than steak and other red meats?
 Please provide an answer
Do you have at least 5 servings of veg & 3 servings of fruit per day?
 Please provide an answer
Do you eat wholegrains (brown bread, pasta & rice) rather than white?
 Please provide an answer
Do you eat ocean-caught fish at least 3 times per week?
 Please provide an answer
Do you avoid fried foods, dressings, sauces, gravies, butter, margarine?
 Please provide an answer
Is your digestive system free from indigestion and irregularity?
 Please provide an answer
Do you get a minimum of 30min exercise 3-5 times per week?
 Please provide an answer
Do you maintain a stable and appropriate weight?
 Please provide an answer
Do you have time to prepare balanced meals rather than eating takeaway?
 Please provide an answer
Do you drink soft drink?
 Please provide an answer
Do you snack on chocolate, biscuits, ice cream (or similar) throughout the day?
 Please provide an answer
Are you free from water retention and bloating?
 Please provide an answer
Do you have the energy and focus you need daily?
 Please provide an answer
Do you drink at least 8 glasses of water a day?
 Please provide an answer
Is your blood pressure, triglycerides & bad cholesterol in normal range?

Are you getting your recommended daily allowance of calcium?
Men under 70 & Women under 50 : 1000mg
Men over 70 & Women over 50 : 1300mg

 Please provide an answer