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your free wellness evaluation form
Kick start on your best shape with this form, specially created for You!
This form is created to understand your lifestyle habits so we can provide you the best advice tailored to your specific needs. We ask 7 - 10 minutes of your time to truthfully complete the wellness evaluation below so YOU, & us, together, can bring out the best in you! We look forward to receiving your evaluation soon and will be in contact with you in no more that 24-48 hours after receiving your evaluation to provide you with a FREE consultation and more information on the various ways we, can support you to being your glorious, NEW self!
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What do you eat for breakfast? *
Required
Lunch: please list ALL examples of what you eat & drink. (if you do not eat Lunch please enter “no lunch".) អាហារថ្ងៃត្រង់៖ សូមរាយឧទាហរណ៍ទាំងអស់នៃអ្វីដែលអ្នកបរិភោគនិងភេសជ្ជៈ។ (ប្រសិនបើអ្នកមិនបរិភោគអាហារថ្ងៃត្រង់សូមបញ្ចូល“ គ្មានអាហារថ្ងៃត្រង់” ។ ) *
Dinner: please list ALL examples of what you eat & drink. (if you do not eat dinner please enter “no dinner".) អាហារពេលល្ងាច៖ សូមរាយឧទាហរណ៍ទាំងអស់នៃអ្វីដែលអ្នកញ៉ាំនិងភេសជ្ជៈ។ (ប្រសិនបើអ្នកមិនបរិភោគអាហារពេលល្ងាចសូមបញ្ចូល“ មិនមានអាហារពេលល្ងាច" ។ ) *
How much plain water do you drink in a day? Please respond in millilitres/litres. If you consume more than 2L, please state in the 'Other' option, your weight & the amount of water you consume in a day (e.g, 51kgs, 2.2L). *
What drinks you do you drink in a day? (you may select more than one.) *
Required
Which part of the day do you feel the need to snack? តើអ្នកមានអារម្មណ៍ថាត្រូវការអាហារសម្រន់នៅពេលណា? *
Required
Select those in your lifestyle(you can select more than one.) *
Required
Your name, & name on Facebook (e.g Chanthida Nou, Chanthida Nou on Facebook) *
Mobile number, if you're using Telegram, please state that number/username too. *
Your instagram username, please. *
Which part of Cambodia are you from? *
Height in centimetres, weight in kilograms. (164cm, 54kgs.) កំពស់គិតជាសង់ទីម៉ែត្រទំងន់គិតជាគីឡូក្រាម។ *
State your preferred/desired weight! បញ្ជាក់ទំងន់ដែលអ្នកចង់បាន / ចង់បាន! *
Select your problem areas *
Required
I want to... (you may select more than one.) *
Required
Choose which describes your facial skin condition.
Clear selection
What have you tried before or is currently doing to achieve your health/weight/fitness goal(s)? (you can select more than one.) តើអ្នកបានព្យាយាមធ្វើអ្វីមុនឬកំពុងធ្វើដើម្បីសម្រេចបាននូវគោលដៅសុខភាព / ទំងន់ / សម្បទា? (អ្នកអាចជ្រើសរើសច្រើនជាងមួយ។ ) *
Required
How long have you been trying to reach your goal weight? *
How often do you exercise in a week? *
How often do you poop in a week? Don't be shy! *
Clear selection
What is your greatest motivation to getting into your BEST shape? តើអ្វីទៅជាការជំរុញទឹកចិត្តដ៏ធំបំផុតរបស់អ្នកក្នុងការទទួលបានរាងល្អបំផុតរបស់អ្នក?
Your consent, please. For us to ask more questions regarding your eating habits and lifestyle habits to gain a better understanding of your body type/daily routine. សូមយល់ព្រមរបស់អ្នក។ ដើម្បីឱ្យយើងសួរសំណួរបន្ថែមទៀតទាក់ទងនឹងទម្លាប់នៃការញ៉ាំនិងទំលាប់រស់នៅរបស់អ្នកដើម្បីទទួលបានការយល់ដឹងកាន់តែច្បាស់អំពីប្រភេទរាងកាយ / ទម្លាប់ប្រចាំថ្ងៃរបស់អ្នក។ *
Select your preferred language for us to reach you. *
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