Your well-being report

Your name

Your e-mail

Your contact at Welness Nutrition :

Your size :

Your weight :

1. What are your eating habits? :

Breakfast :

Morning snack :

Lunch :

Afternoon snack :

Evening meal :

Evening snack :

Do you tend to snack? :
YesNo

Do you prefer food? :
SweetSaltedFat

Do you eat ready-made meals (trays, tins, etc.)? :
YesNo
If so, what kind? :

Do you eat fruit? :
LittleMediumMany

Do you eat vegetables? :
LittleMediumMany

Do you eat out of emotion? :
LittleMediumMany

Do you eat portions? :
PetiteAverageGrande

Do you drink water? :
YesNo
If so, how much per day (in litres)? :

Do you drink soft drinks? :
YesNo
If so, what type and in what quantity (in litres)? :

Do you drink coffee, tea or anything else? :
YesNo
If so, what type, how much and how much sugar per cup? :

Do you drink alcoholic beverages? :
YesNo
If so, what type and how much? :

Do you smoke? :
YesNo
If so, how much? :

Do you do any physical activity (sport)? :
YesNo
If so, how many hours per week? :

What are your objectives?

2. Vitality and well-being

Do you suffer from digestive problems? :
YesNo

Are you feeling tired? :
YesNo

Are you retaining water? :
YesNo

Do you have a heart condition? :
YesNo

Do you have diabetes? :
YesNo

Do you have a thyroid disorder? :
YesNo

Are you taking any medication? :
YesNo

3. Magnifique" gift recommendations

Recommendations of your 5 to 10 contacts to whom you would like to offer the same wellbeing assessment. Indicate their surname, first name and telephone number or e-mail address. At least 2 people must be included so that we can analyse your assessment and get back to you! For every 5 contacts you recommend, you'll receive your FREE Fitmarathon Discovery PACK (minimum value €58). For 10 recommended contacts, you'll receive your FREE Fitmarathon Discovery PACK (min. value €58) + 1 box of snacks of your choice (protein snacks or crisps). Contact us for more information.

Person 1:
Name :
Tel:
Email :

Person 2:
Name :
Tel:
Email :

Person 3:
Name :
Tel:
Email :

Person 4:
Name :
Tel:
Email :

Person 5:
Name :
Tel:
Email :

Person 6:
Name :
Tel:
Email :

Person 7:
Name :
Tel:
Email :

Person 8 :
Name :
Tel:
Email :

Person 9 :
Name :
Tel:
Email :

Person 10 :
Name :
Tel:
Email :

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