Our
2 minute survey
This questionnaire has been
designed to establish your personal requirements. Please answer
all of the questions below by ticking the appropriate box.
This is not a diet plan,
nor slimming pills, instead weight management through outstanding
herbal based nutrition. "More to losing weight than counting
calories"
Over 18 only please, if
under 18 please complete with assistance of parents.
Please answer all of the questions below by ticking the appropriate box.
1.Do
you want to lose weight right now?
Yes
No
2. Why do you want to lose weight / Is there a specific reason?
(holiday, medical reasons,
birthday, ........)
3 . What
kind of weight loss programs have you tried?
Counting
calories or points
Low
fat diets
Low
carb / high protein
Meal
replacement drinks
Other
(please specify)
3a If you have tried losing weight before - did the plans work for you?
4 . How old are you?
5 . How tall are you?
6 . Approx weight?
7.
How much weight would you like to lose?
0-3 lbs
4-7 lbs
8-14 lbs
14-28 lbs
28 lbs +
8. When are you looking to lose the weight by?
9 .
Do you eat 3 meals a day?
Yes
No
10 . If no, which meal/meals do you miss.
11. Do you tend to get hungry throughout the day?
Yes
No
12 . Do you experience a loss of vitality
during the day? Give details
Yes No
Occasionally
13 . Any health challenges? IBS, Diabetes, Arthritis,
sleep problems, high cholesterol, heart disease etc etc. Are you on any
medication?
14.On
a scale of 1 to 10 how serious are you about losing weight?
15. Additional information
Name
Email
Telephone
evening
Telephone day
Best time and day to call
Telephone consultations
between 9am -9 pm on landline telephones
Please note:
Please check
that your contact details are correct before submitting this form.
