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FREE Preliminary Wellness Evaluation
Please complete the below as accurately as possible (Mandatory fields are marked with a red asterisk)
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Are you interested in joining the 21 day body transformation challenge with the R25'000 Cash Prize for the winner?
Yes
No
Clear selection
Name & Surname
*
Your answer
Gender
*
Female
Male
Age
*
Your answer
Mobile Contact Number
*
Your answer
Your residential Suburb/Town/City
*
Your answer
Country of Citizenship
*
Your answer
Your Height [centimeters / meters / feet] (Please estimate if uncertain)
*
Your answer
Your Weight/Mass [Kilograms / Pounds] (Please estimate if uncertain)
*
Your answer
What do you usually have for breakfast?
*
Nothing
Cereal
Toast
Coffee
Tea
Juice
Muffin
Bagel
Milk
Eggs
Doughnuts
Other:
Required
Do you ever feel hungry during the day?
*
Never
Occasionally
Always
Other:
Do you suffer from any of the following?
*
Weight gain
Fatigue
Migraines/Headaches
Constipation
Muscle cramps
Dry skin/mouth
Elevated Blood Pressure
Bad breath
None of the above
Other:
Required
Do you know how much water you should be drinking daily?
*
Yes
No
How much water do you drink daily? [litres / Pints / Gallons]
*
Your answer
Would you be interested in doing a free full body composition assessment in-person?
*
Yes
No
Other:
How many times would you say that you eat out (not home cooked meals) during a month?
*
0
1
2
3
4
5
6
7
8
9
10
or more
How many times would you say that you exercise (more than 30 minute sessions) during a week?
*
0
1
2
3
4
5
6
7
What time do you usually wake up in the morning?
Time
:
AM
PM
What are your Wellness Goals?
*
Lose Weight
Gain Weight
Maintain Weight
Tone / Build Muscle
Athletic - Improve Endurance
Athletic - Improve Strength / Recovery
Feel more Energetic
Other:
Required
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Enter any additional comments, requirements, or questions you may have here...
Your answer
Please tell us who referred you here? (if any)
Mohamed Mansoor
Zakiyya Mansoor
Other:
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How would you prefer we send your results back to you?
Email
WhatsApp
Telephone Call
Other:
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