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Health Check

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

Full name

First and last name
2

Your first and last name

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3

How would you rate your current wellbeing?

How do you feel? How much energy would you say you have?
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4

How much water do you drink a day?

Plain water only, other drinks don’t count into this.
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5

How often do you exercise on a weekly basis?

Select one answer
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6

Do you consume caffeine to boost your energy or productiveness?

Select one or more answers
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7

Do you suffer from headaches or migrane?

Select one or more answers
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8

Do you struggle to concentrate and focus?

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9

Do you suffer from joint pain or tense muscles?

Select one or more answers
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10

Do you suffer from hairloss?

Select one or more answers
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11

Do you have any issues regarding your scalp such as psora or eczema?

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12

Do you suffer from bad digestion?

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13

Do you often feel tired or exhausted?

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14

Do you currently take any supplements to avoid vitamin deficiency?

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15

How often do you get sick per year?

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16

Do you have any intolerances or food allergies?

Select one or more answers
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17

How would you rate your current diet?

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18

How content are you with your body/weight right now?

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19

How much are you willing to invest in your health on a monthly basis?

Select one answer
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20

On which whatsapp number can I reach you once I’ve analysed your responses?

I’m looking forward to it :) Thanks!
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