NADIA
SHALWANI
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YOUR ONLINE ASSESSMENT
By completing the following 10 minute assessment, I will have the essential information to start getting you ready for your wellness journey.
You can also download the assessment
here
and return it by email.
Full Name
Occupation
Email
Phone
Todays Date
Referred By
Address
Age
Height
Weight
Health History
Current Medications
Current Nurtition Supplements
Women Only: Do you currently have a menstrual cycle?
What would you like to achieve? What would reaching your goals do for you?
Please list any specific previous nutrition/fitness programs you've followed (including any fad diets)
In your opinion, what made you successful? What were some of the barriers to maintaining success?
In what part/s of your body do you feel you carry the majority of your weight/body fat?
Water Intake
Caffeine Intake
Alcohol Intake
Digestion
What do you crave the most?
Salt
Starches
Sugar
Average Stress Level (0 to 10, with 10 being overwhelmed)
Choose an option
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How Are You Managing Your Stress?
What time do you go to bed?
What time do you wake up?
Quality of sleep?
Energy Level (1 to 10 with 10 being very energetic)
Choose an option
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What activities are you currently participating in?
Current Strength Training Schedule/Routine?
Anything else you would like me to know?
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