Fairfield Park, Bath, UK, BA1 6NF
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Sanela Mujakovic, Nutritional Therapist, Herbalife Nutrition Health Coach & Weight Loss Specialist, Bath, UK: Healthy with Sanela: get into the best shape of your life, for life!

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FREE “How Healthy Is Your Lifestyle?” Online Quiz

FREE Online Wellness
Evaluation Questionnaire

How healthy & balanced is your diet? Find out today!

If you often wish: “I want to eat better and live healthier?”, “I wish I had more energy” or “I want to lose weight!” wanting to look as well as feel different so you can perform better in all aspects of your life – then this quick & free online evaluation is for you!

Assessing your current food & lifestyle choices & habits can help you gain insights where you may be falling short and how you can improve it in order to reach your wellness goals.

This valuable free service is my gift to you, analysis is done by me personally, it will point out where you may be going wrong and will offer recommendations on how to reach your wellness & weight management goals.

Free Wellness Evaluation Questionnaire

1Your Goals

2Body Composition

3Your Nutrition & Lifestyle (Part 1)

4Your Nutrition & Lifestyle (Part 2)

5Digestve Health

6Heart Health

7Immune Health

8Skin Health

9Other Lifestyle Habits

10Contact Information

Form only takes 5 minutes to complete!

Your Goals

Please identify one or more of your goals *

HEALTH & WELLNESS: Want to improve your energy levels, get leaner or kick start your Healthy, Active Lifestyle?
WEIGHT MANAGEMENT: Want to lose weight in a healthy & sustainable way and establish a Healthy, Active Lifestyle?
FIT & ACTIVE: Ultimate goal a lean and toned physique? To optimise your diet before, during & after exercise?
TARGETED HEALTH: Improve Digestive Health, Immune Health, Skin Health and/ or Heart Health

Please fill in the basic information below so that your Body Composition Requirements can be established: BMI, Daily Protein Factor & Optimum Energy Intake

Your Gender *

Male
Female

Your Height *

Your Weight *

Your Age *

Your Nutrition & Lifestyle (Part 1)

1. Do Your Have Breakfast Every Morning? *

Yes
No

2. What do you normally have for breakfast? *

Nothing
Cereal
Toast
Muffin
Youghurt
Fruit Juice
Eggs
Coffee
Meal Replacement Shake

3. Do You snack throughout the day? *

Yes
No

4. What are your regular snacking choices? *

Nothing
Crisps
Biscuits
Fruit
Coffee
Eggs
Yoghurt
Nuts
Dried Fruit
Protein Bar
Sandwitch or toast

5. Do You drink minimum 2 litres of water per day? *

Yes
No

6. Do you eat more meals with poultry, lean meat, fish and plant (soy) protein rather than steaks, roasts and other red meats? *

Yes
No

7. Are you free from processed meats like salami & bacon? *

Yes
No

Your Nutrition & Lifestyle (Part 2)

8. Do you get a minimum of 30 minutes of exercise 3-5 days a week? *

Yes
No

9. Do you maintain a stable & appropriate weight? *

Yes
No

10. Do you always have the energy & focus you need to meet your daily challenges? *

Yes
No

11. Are you free from cravings for sugar (sweets, cakes, biscuits, etc.) and other carbohydrates (crisps, toast, crackers, etc.)? *

Yes
No

12. Are you free from water retention? *

Yes
No

13. Do you usually have time to prepare balanced meals, rather than take aways or eating on the run? *

Yes
No

14. Do you stay away from fizzy drinks & fruit juices throughout the day and after meals? *

Yes
No

15. Do you consume less than 4 teas or coffees a day? *

Yes
No

Digestive Health

16. Is your digestive health free from indigestion or irregularity? *

Yes
No

17. Do you suffer from bloating & gas? *

Yes
No

18. What are your biggest digestive challenges? *

19. Do You know if your intake of fibre is over 25 grams per day? *

Yes
No
Don't know

20. Do you consume primarily whole grains (100% whole wheat bread/ pasta, brown rice rather than white bread, white rice or regular pasta)? *

Yes
No

21. Do your pants get tighter after a small meal or do not fit at all? *

Yes
No

22. Are you free from diarrhea or lose stools? *

Yes
No

Heart Health

23. Are Your blood pressure, triglycerides and cholesterol in the normal range? *

Yes
No

24. If NO, what are your heart health challenges? *

25. Do you eat ocean-caught fish at least 3 times a week? *

Yes
No

26. Do you avoid eating fried foods, dressings, sauces, gravies, butter and margarine? *

Yes
No

27. Do you supplement with Omega 3? *

Yes
No

28. Are you on any Heart medication? *

Yes
No

Immune Health

29. Are you free from brittle fingernails and toenails? *

Yes
No

30. Are you free from frequent antibiotics? *

Yes
No

31. Are you free from frequent colds & flu? *

Yes
No

32. Do you supplement with at least a high quality Multivitamin & Mineral each day? *

Yes
No

33. Do you eat at least seven servings of a variety of colourful fruits & vegetables each day? *

Yes
No

34. Are you getting daily recommended amount of Calcium? *

Yes
No

(To get enough of Calcium in your diet you need about 3 portions of daily products each day (1 glass of milk = 1 portion) or plenty of other Calcium rich foods such as tofu, canned fish, green leafy vegetables, nuts and seeds)

Skin Health

35. Is your skin healthy & free from dryness, psoriasis, acne or itchiness? *

Yes
No

36. If NO, what are your biggest skin challenges? *

37. Do you Cleanse, Tone, Moisturise your skin daily? *

Yes
No

38. Are You happy with your skin? *

Yes, very happy
Somewhat, but I would like to improve it
No, I am really desperate to get my skin look & feel better!

Other Lifestyle Habits

39. Are you free from smoking? *

Yes
No

40. Would you say that your stress levels are low most of the time? *

Yes
No

41. Do you get ideally 7-8 hours of sleep per night? *

Yes
No

42. Do you consume less than 14 units of alcohol per week? *

Yes
No

(Equivalent to 6 pints of beer or 7 glasses of wine)

Your Contact Details

Where Can I send back the results & my feedback?

Name *

First

Last

Email *

Phone *

Do you prefer to be emailed or discuss it over the phone: *

Email My Wellness Evaluation
Call Me to Discuss My Wellness Evaluation

Best Time To Call *

Please Clarify Your Interest *

I am very excited about working with you & kickstarting my Healthy, Active Lifestyle
I am interested in improving my health, but need more convincing this is right for me.
At this point, I am just curious how I score & what advice I will get!
This is not the right time for me, but I am open to filling in the form & receiving feedback.

Anything else you would like me to know about your health & current challenges before submitting?

Thank you!

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Disclaimer: All references to weight management relate to the Herbalife Nutrition Weight Management Programme which includes, amongst other things, a balance diet, regular exercise, an adequate daily fluid intake, nutritional supplementation where required and appropriate rest. Individual results will vary. Herbalife Nutrition Products do not prevent, treat or cure disease or medical conditions. They are quality nutrition supplements that aid good health as a part of a Healthy, Active Lifestyle.

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