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This questionnaire
has been designed to establish your personal requirements. Please answer all of the questions below by ticking the
appropriate box.
Serious enquiries
only please. Experienced consultants available to offer advice.
1.Which of these best
describes your own lifestyle?
Calm
Active
Stressed
2.Do you think you
get 100% of the daily nutrition needed for good health?
Yes
No
Sometimes
3.Do you take
nutritional supplements (vitamins/minerals/proteins)
Daily
Never
Sometimes
4.Do you experience a
loss of vitality during the day? Give details
YesNo
Occasionally
5. Do you eat 3 meals
a day?
Yes
No
6. If no, which
meal/meals do you miss.
7.Irregular meals or
eat late? Please give details
8.Do you smoke?
Yes
No
9. Sweet tooth?
Like sugary
foods/chocolate
Really
like sugary snacks
Really,
really like sugary snacks! (multiple choc bars)
Don't
like sugary snacks
Other snack
consumption
10. How much still
water to you drink each day?
3+
litres
2+litres
1+ litre
odd glass
Fizzy drink
consumption :
11.Any health
challenges? IBS, Diabetes, Arthritis, sleep problems, high cholesterol,
heart disease etc etc
11a Have you been diagnosed or suspected
as having Diabetes?
When was your diagnosis?
This
week
This
month
This
year
Other
Not
yet diagnosed
11b Which type have you been diagnosed
with?
Type
I
Type
II
Other?
Please give details
11 c What medication, if any, are you taking?
12.Body shape
You have more than
10lbs to lose and you tend to carry your excess weight around your
middle rather than all over? (i.e. an "apple" body type affects 20% of
population)
Yes
No
Are you sensitive to excessive carbohydrate intake? In other words,
if you eat biscuits or bread, do you find yourself immediately craving
more?
Yes
No
If you eat a chocolate bar, do you find you feel fatigued or
jittery half an hour later?
Yes
No
13. You have less than 10lbs to lose but those stubborn inches are
on hips, thighs & bum
Yes
No
14.What type of work
do you do ie sedentary, active, at home
15. How have you
tried to lose weight before? You may select more than one
Counting calories or
points
Low fat diets
Low carb / high protein
Meal
replacement drinks
Other (please specify)
16.What is your
weight loss goal?
0-3 lbs
4-7 lbs
8-14
lbs
14-28
lbs
28 lbs +
17.When are you
looking to lose the weight by?
0-4 weeks
4-8
weeks
8-12
weeks
3-6
months
6-12
months
ASAP - I'm serious and committed
18.Why do you want to
lose weight?
To look good
To have more self-confidence
For health reasons
I'm going on holiday
I'm attending a special event
Other (please
specify)
19.How much are you
prepared to spend per day to achieve your goal?
Less than £1.00
£2.00
"I couldn't believe the money I saved on
£3.00
on my food bill using this programme"
£4.00
Kerry Ogden, Peterborough
£5.00
20.How old are you?
21.How tall are you?
22.Approx weight?
23.What is your ideal
goal ?
24.Addditional
information
25.How serious would you say you are
about your losing weight?
- Extremely
serious
- Fairly
serious
- It doesn't really worry me
26.How serious would you say you are
about maintaining long term good health by looking after your body
now?
- Extremely
serious
- Fairly
serious
- It doesn’t really worry me
Name
Email
Telephone Evening
Telephone Day
Mobile
Free consultation provided by phone
on landline numbers.
Please check your contact details or
we cant help you.
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