1.What are your meal patterns like 

3 meals a day

More than 3 meals a day

Irregular meals

Less than 3 meals a day

2.Food consumed.

How much do you eat on an average day?

Very little                               Same as everyone else                               lots and lots
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3.What are your energy levels like

Below average

Average

Above average

4.Give yourself a rating on negative nutrition (smoking, coffee drinking, fast food, processed food, stress, medication) out of 10.

lots of fast food, smoking, coffee, alcohol, fizzy drinks....							Very healthy diet / great absorption
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5.How have you tried to gain weight before?

6.Do you play sports or exercise or go to the gym? Please advise details

7.What type of work do you do i.e. office work or physically demanding work?

8.How old are you?

9.How tall are you?

10How much do you weigh?

11.How long have you been at this weight

12.What is your ideal goal weight?

13.Addditional information e.g. general health:

14.How much would you be prepared to spend per day to achieve your goal?

Less than £1.00

£2.00

£3.00

£4.00

£5.00

15.On a scale of 1 to 10 how serious are you about gaining weight?

Not worried								Extremely serious
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Name  

Email 

Prefer a chat on the phone? 0121 2880659 9 am to 9 pm

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