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Facial Party/Spa
Inspirational
Weight Loss Challenge
Health & Lifestyle Survey
Blog
Home
About
Photo Gallery
Holidays
Contact
Services
Facial Party/Spa
Inspirational
Weight Loss Challenge
Health & Lifestyle Survey
Blog
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?
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Indicates required field
Which of these words best describes your own lifestyle?
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Calm
Active
Stressed
Have you tried diet programs in the past?
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Yes
No
Which ones?
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Do you think you get 100% of the daily nutrition needed for good health??
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Yes
No
Sometimes
Do you eat a variety of healthy foods from the basic food groups every day?
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Yes
No
Do you take nutritional supplements (vitamins/minerals/proteins)?
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Yes
No
Sometimes
If no, why not?
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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?
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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?
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Yes
No
Do you experience a loss of energy during the day?
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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
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Friends
*
Family
*
Family
*
Friends
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Would you prefer further information to be sent to your home or office?
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Yes
No
your Information:
Name
*
First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Cell/Work Phone No.
*
Submit