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Free Wellness Evaluation

I offer FREE advice on your health, lifestyle or weight problems. Please answer the following questions, so that I can better assist you with your needs. All information you provide is strictly confidential so please give as much information as you can. Please only complete this form if you are serious about your health and are really interested in a free health assessment. I give of my time freely and would appreciate it if you would respect this and not fill in this form with nonsense.

Yours in health

Trish Towsey
Certified Life Coach



We offer FREE advice on your health and/or weight problems.
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name
E-mail Address*
City*
Country*
Would you or a member of your family like to lose weight?
If so how much?
3-5kg
5-10kg
10-20kg
20kg and over
Have you had any health problems?
If so what is the problem?
How long have you had it?
What have you tried?
Do you wake up feeling tired?
Yes
No
Do you suffer from energy loss during the day?
Yes
No
What is your current weight?
What is your goal weight?
What is your height?
What is your age?
Gender
Male
Female
Have you tried any weight loss programmes?
Yes
No
If so which programmes have you tried?
How often do you eat out?
1x week
More then that
2x month
3x month
How often do you eat fast food?
Every day
More than 2x week
1x week
1x month
2x month
Do you exercise?
If so how often?
What exercise do you do?
How much water do you drink per day?

Please enter the word that you see below.

  



Please note that this assessment does not replace a consultation with your medical practitioner.See disclaimer below.


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