Little Paradise
Wedding & Conference Venue, Springs
Little Paradise Wedding and Conference Venue, Springs
Online Wellness Survey
Online Wellness Survey
© Little Paradise Venue, Weddings & Conference Venue, Springs, Gauteng, South Africa     Disclaimer     Design  
Tel. 011 811 2750 / Cell 082 442 0177
Little Paradise, Wedding and Conference Venue. 79 Robertson St. Petersfield, Springs, Gauteng

 

 

Online Wellness Survey

 

*  Please complete all fields

 

1

Name and Surname

 

2

Email Address

 

3

Contact Number

 

4

Age

 

5

Height

 

6

Date of Birth (yy/mm/dd)

 

 

 

 

 

 

Questionnaire

 

 

Tick

7

What do you usually have for breakfast?

Nothing

 

 

Cereal

   

Coffee

   

Toast

 

 Other

     

8

Do you feel hungry during the day?

Never

   

Sometimes

   

Always

     

9

Do you have energy problems?

Yes

   

No

   

Sometimes

   

Always

     

10

Is your digestive system regular?

Yes

   

No

   

I am battling

     

11

Do you suffer from any of the following?

Headaches

   

Bloating

   

Constipation

   

Swollen hands, feet

   

Muscle & Joint pains

     

12

Do you know how much water you should be drinking daily?

Yes

   

No

   

I don't know

     

13

What is your weight?

Kg

     

14

Highlight if you have any of the following:

Diabetes

   

Cholesterol

   

High Blood Pressure

   

Low Blood Pressure

 

 Other

     

15

What is your goal?

Lose weight

   

Gain weight

   

Maintain weight

   

Build Muscle Mass

     

Your Wellness Coach is Rene Venter

 

 


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Little Paradise Wedding & Conference Venue, Springs
© Little Paradise Venue, Weddings & Conference Venue, Springs, Gauteng, South Africa     Disclaimer     Design