Health & Lifestyle Survey

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Photo Gallery
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Contact
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Health and LifeStyle Survey

Hello. Welcome to my page. If you can spare a few minutes, I would really appreciate your help in completing a short but important survey on your health and lifestyle?

* Indicates required field

Which of these words best describes your own lifestyle? *

Calm Active Stressed

Have you tried diet programs in the past? *

Yes No

Which ones? *

Do you think you get 100% of the daily nutrition needed for good health?? *

Yes No Sometimes

Do you eat a variety of healthy foods from the basic food groups every day? *

Yes No

Do you take nutritional supplements (vitamins/minerals/proteins)? *

Yes No Sometimes

If no, why not? *

Not enough time for shopping/preparing Too expensive Too complicated

Do you, or does any member of your family or friends need to lose, gain or maintain weight? *

Lose Weight Maintain Weight Gain Weight Can't say for certain

Are you interested in learning about a nutritional program to control weight while still eating the foods you like, without feeling hungry? *

Yes No

Do you experience a loss of energy during the day? *

Yes No Occasionally

When is the most suitable time & Day to contact or Telephone you?

Day *

Time *

Approximately how much weight do you/they need to lose?

You *

Family *

Friends *

Family *

Friends *

Would you prefer further information to be sent to your home or office? *

Yes No

your Information:

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell/Work Phone No. *

Submit