Skip to content

Our Programs
- Vitality Based Ageing
- Weight Loss and Wellness Individual Couple or Family Plans
About Us
Challenges
- Reset Your Life in 21-Days
- Total Body Clean-Up Challenge
Wellness Tips
Seminars & Workshops
Contact Us

Our Programs
- Vitality Based Ageing
- Weight Loss and Wellness Individual Couple or Family Plans
About Us
Challenges
- Reset Your Life in 21-Days
- Total Body Clean-Up Challenge
Wellness Tips
Seminars & Workshops
Contact Us

Lifestyle Questionnaire

Name

PERSONAL STRATEGY QUESTIONNAIRE

Please complete this questionnaire as honestly as you can. There are no right or wrong answers, and everything you share will be kept strictly confidential. Once you have completed it, please click “Submit” so we can discuss your next steps.

First Name *

Last Name *

Date of Birth

Phone Number

Email Address *

Street Address

Suburb

Post Code

Are you currently experiencing any health issues, pain, uncomfortable physical symptoms, or mood problems? *

Yes

No

What aspects of your health would you like to focus on? (Select all that apply) *

Easier weight loss

Eliminate water retention and bloating

Smoother, clearer skin and brighter eyes

Waking up well-rested and refreshed

Enhanced concentration and sharper mind

Clearer sinuses - not blocking up

Eliminate bags or dark circles under my eyes

Better digestion and bowel movements

Fewer aches and pains

Improve my immune system

Fewer infections

Alleviate symptoms of female PMS

Other

Take an inventory of your usual grocery shopping basket

How likely are you to buy pastries, cakes, biscuits, ice cream, desserts, or other sugary snacks? (1 being unlikely and 5 being highly likely) *

1

2

3

4

5

How likely are you to buy crisps, cheese crackers, salted peanuts, or other fatty snacks? (1 being unlikely and 5 being highly likely) *

1

2

3

4

5

How likely are you to buy ready meals, frozen burgers, frozen pizzas, hot dogs, sausages, cured meats, or other fast foods? (1 being unlikely and 5 being highly likely) *

1

2

3

4

5

If someone told you that you need to give away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your detox goals, would you do it? *

Yes

No

Have you worked with a nutritional advisor in the past? *

Yes

No

If yes, please specify the type of provider and the results you obtained or did not obtain

Thank you for completing our questionnaire! We look forward to reading your responses and connecting with you to arrange the next phase of the process!

Please click the submit button below

antispam

CALL US

Call 0404 833871 to book your appointment

Level 13/50 Cavill Ave, Surfers Paradise QLD 4217

EMAIL US

info@jkwellnessnutrition.com

FOLLOW US

© 2018 JK Wellness and Nutrition | Site by Macarthur Websites

5 CLEAN EATING HACKS

In this guide, we will cover

How to avoid foods that are wreaking havoc on your body and causing unwanted symptoms!
How to eat clean so you can feel incredible and enjoy food that is not only good for you but also tastes delicious!
How to save time and prepare healthy meals even if you’re busy and work a 9-to-5!
And so much more!

5 Hacks for Clean Eating