This questionnaire
has been designed to establish your personal requirements. Please answer all of the questions below by ticking the
appropriate box.
Note this is not a diet plan instead weight management through good
nutrition. "More to losing weight than counting calories"
We will respond to every questionnaire we receive. We will contact
you within 48 hours.
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!
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
12.Body shape
You have more than 10lbs to lose and you carry your excess weight
around your middle rather than all over? (i.e. an "apple" body type affects 20% of the 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/information required e.g. questions, recommended programme
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
Telephone Evening
Telephone Day
Best time to contact?
Free consultation provided by phone on landline numbers. Hard to contact, never in, no landline number? Phone us on 01673 838 916 after completing the questionnaire. Please contact us at least 30 mins after filling in the questionnaire. You can reach us up until 9pm
Please check your contact details or we cant help you!
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