Survey - CoreVita Wellness

Let us get to know you more!

R695

R 550

Monthly

Well Balanced Meal Plan
Recipes
Coaching and Support
Weekly Weigh-In
Individual Advice and Support
Tips and Guidance for Maximum Weight Loss
Personalized Meals Plan
New Plan every 2 Weeks

Popular

Name

First

Last

Address

Outside of Swellendam Area counts as Online Client

Gender

and following for

Contact Number

R 100 Admin Setup Fee ( in person only )

I accept
I don't Accept

*This is not applicable for Online Clients. The admin fee is standard and covers time, document handling, and materials. The folder is part of it, but not the only reason for the charge. If you don't accept you wont receive a folder.

Height (cm)

Selected Value: 40

Weight

Goal Weight

Blood Type

Any Food Allergies?

Any Chronic Illnesses?

History with diets - what type of diet did you do previously?

Will you say you are an emotional/over eater and why?

Do you eat breakfast? When and what do you usually eat?

When and what do you usually eat for lunch?

When and what do you usually eat for dinner?

Do you snack regularly, and what do you snack on?

What type of food do you like or prefer a lot?

What type of food do you not eat?

Who prepares the food in the house?

How many times are you social in a week/eat out or takeaways?

How many times a week do you use alcohol?

How much time do you take to plan your meals or meal prep?

Why do you want to lose weight?

I would like to make use of the following method to lose weight

Let us get to know you more!

Basic Package