Live healthy, live better.

Every day we search for ways to feel better so that our days and those of our close ones can be more pleasant.
The recipe of success remains in a balanced diet, combined with a sufficient consumption of water as well as the practice of physical activities.
By combining these three key elements of a daily improved well-being, you give yourself an opportunity to feel good day after day.
Please fill out and send the form below to receive your free Wellness evaluation!

Your information is kept strictly confidential!
We do not share or sell any information about you with anyone!
* All questions must be answered, otherwise this questionnaire cannot be sent *
  First Name
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  Last Name
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  Email Address
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  City
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  Country
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  Telephone N° (+ Area Code)
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  Best time to contact you
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To calculate your Body Mass Index
  Gender (Female or Male)
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  Your Age
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  Your present weight
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  Your height
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  1 - Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than         steaks, roasts and other red meats?   ??
  2 - Do you eat a variety of colorful fruits and vegetables and do you eat at least seven servings         per day of these?   ??
  3 -Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice)        rather than regular pasta, white rice and white bread?   ??
  4 - Do you eat ocean-caught fish at least three times per week?   ??
  5 - Do you usually eat fried foods, dressings, sauces, gravies, butter and margarine?   ??
  6 - Do you have problems with your digestive system (indigestion or irregularity)?   ??
  7 - Do you get a minimum of 30 minutes of exercise three to five days a week?   ??
  8 - Are you overweight?   ??
  9 - Do you usually have time to prepare balanced meals, rather than take-out or eating on the         run?   ??
10 - Do you usually eat soda and typical snack foods throughout the day and after dinner?   ??
11 - Do you have problems with water retention and bloating?   ??
12 - Do you have the energy and focus you need to meet your daily challenges?   ??
13 - Do you drink at least eight glasses of water a day?   ??
14 - Are you getting your daily recommended allowance of Calcium? A: Men = 1,000mg
        B: Women under 50 = 1,200mg C: Women 50 and older = 1,500mg? 		  ??
15 - Do you have problems with your blood pressure, triglycerides and cholesterol?   ??
16 - Women: Do you have problems associated with your menstrual cycle/menopause such as         mood changes, hot flashes or problems sleeping? (Men? Select - NO)   ??
17 - Men: Do you have problems associated with your prostate such as slow urination or waking         up at night to urinate? (Women? Select - NO)   ??

*Optional
Do you have precise health and wellness objectives?

Please type in the box below.


Thank you for your trust!
Please press on "Send" below.

     


PS., After having sent this questionnaire, you will be directed to a confirmation page.
If it does not work, please verify that you have answered all the questions.
If you are a woman, select NO on question #17. - If you are a man, select NO on question #16.

This free evaluation is offered to you by:

Your Personal Wellness Coach
Guylaine Dupont - Quebec, Canada - 418-325-3069

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