Lifestyle Survey

Your current lifestyle provides information that can help to design the best approach to reach your goals. Please complete and submit the form to help to find out how you can tweak your lifestyle to achieve your health goals.

Please ignore any questions you are not comfortable answering.

Roël :)

What is your date of birth?

What prompted you to book a session?

How would you describe your current state of health?

What is the single most important thing with regards to your health that you would like to change?

Have you ever tried to improve your life style and what were the results?

What type of physical activity do you do and how often?

How much time do you spend walking each day?

What do eat and drink on an average day? Describe the foods and drinks and if possible, add the portion size.

What are your 10 favourite healthy foods?

What are your 10 favourite unhealthy foods?

On average, how many hours do you sleep each night?

How would you describe your stress levels?

Do you suffer from any illnesses or ailments and are you on any medication (if so, which)?