top of page
FAITH HOMOEOPATHY
Online/Maidenhead Clinic
Book Now
Log In/Sign Up
Welcome
Clinics
Online Consultation
Maidenhead Clinic
Free Pre Consultation
Appointments
Booking From India
Health Conditions
Weight Loss Program
Menopause Clinic
Chronic Pain Relief Hub
Physiotherapy
Acupuncture
About Us
FAQ
Testimonials
E Books
Blog
Contact
Submit your form today!
Health Assessment Questionnaire
First name
Last name
Email
Contact Phone Number
Have you joined the Faith Fitness Program?
Yes, I have joined
No, I am planning to join
No, I would like more info
What is your primary goal for joining Faith Fitness?
Achieve weight loss
Fitness improvement
Improve general wellbeing
Reduce risk factors for heart attack and stroke
Improve menopause symptoms
Improve specific health concerns
What is your age and current weight?
Do you have any of the following risk factors for heart attack and stroke?
Diabetes
High Blood Pressure
High Cholesterol
Obesity
Sedentary Lifestyle
Smoking
Unhealthy Diet
No Risk Factors
Are you a post/perimenopausal woman? Let us know the symptoms that affect you.
Changes in mood - such as low mood or irritability
Changes in skin conditions, including dryness or increase in oiliness and onset of adult acne
Difficulty sleeping – this may make you feel tired and irritable during the day
Hot Flushes
Joint stiffness, aches and pains
Other symptoms
Not applicable
Do you have any existing health issues or concerns? If yes, please specify.
Please select the option that best describes your current level of activity and fitness.
Sedentary Lifestyle: I have a predominantly sedentary lifestyle with minimal physical activity.
Light Activity: I engage in light activities throughout the day, such as household chores or short walks.
Moderate Exercise: I participate in regular moderate-intensity exercises, such as brisk walking, cycling, or swimming.
Intense Workout: I engage in intense workouts or high-intensity activities, such as running, weightlifting, or intense sports.
Athlete Level: I have a high fitness level and engage in advanced athletic training or competitive sports.
Do you have any dietary preferences, restrictions, or allergies that need to be considered when providing nutrition guidance?
Please list your current medications or supplements. This information is important to ensure that the fitness program and nutritional recommendations are safe and suitable for you.
We value your privacy and confidentiality. However, if you are comfortable sharing the above information with our nutritionist and fitness instructor, it can greatly help them in understanding your current activity level and designing personalised plans to support your fitness and nutrition goals.
Yes, I am happy for my health information to be shared with the nutritionist and the fitness instructor
No, I would prefer not sharing
Would you be open to receiving email updates about the Faith Fitness program? We would like to keep you informed about any new developments, special offers, or updates related to our program.
Yes
No, Thanks
Submit
bottom of page
.png)