5min Wellness Questionnaire

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Thank you for taking time to answer some questions about your health and wellness goals.

As your Health Coach I can't wait to read them to chat further about how we can work on them together! :)

Name *

Email
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WhatsApp Contact number and Country Code
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Instagram/ Facebook Handle

How would you rate your daily energy levels?
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Good energy in the morning, but afternoon slump is a real thing

Struggle with my mornings, but full of energy as the day goes on

I have great energy and don't notice many dips at all

Other:

Required

How would you rate your body confidence?
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1 - I have no confidence & am unhappy with my body

5 - Feeling confident, feeling great, feeling positive

What are your current health goals?
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What does your average breakfast look like?
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How often do you move your body?
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I hardly workout, sometimes never

I move my body is some way every day

I exercise 1-3 times per week

I exercise 4-5+ times a week

How much sleep do you get per night on average?
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Less than 5 hours

5-7 hours

7-8 hours

How much water do you drink daily?
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1 litre on a good day

1-2 litres

2- 3 litres

More than 3 litres

I struggle with water intake

Do you struggle with any of the following with regards to digestive health?
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Bloatedness

Constipation

Upset tummy, often

Gassy

Painful spasms

Irregular bowel movements

None of the above

Required

What do you crave?
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Sugar

Salt

Both

Neither

How often do you consume alcohol?
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How often do you consume alcohol?

2 - 3 times a week

I have a glass of wine/night cap to wind down my day, most nights

I don't drink alcohol.

What would you like to focus more on?
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Shape up

Weight / Muscle Gain

Healthy Habits

Gut Health

Increase energy levels

Glowing Skin

Clean up my eating

Learn basic health benefits

Feel better

Get more active

Required

Do you need an accountability partner?
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Yes, that would help alot

No, i like doing my own thing

A weekly "check in" would be great!

Are you currently using any supplements? If so, which ones?
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Would you be interested in joining my 10 day intro community?
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Yes, sounds like fun

Tell me more

Required

Feel free to add anything extra below
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I'll be in touch soon! :) Leigh xxx
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