HEALTH & LIFESTYLE SURVEY

Please take a few minutes to take part in this survey on important health and lifestyle issues.

Health & Lifestyle Survey Form

 

1. Which of these words 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 (vitamin/minerals/proteins)?

   Daily  Never  Sometimes

 

4. Do you experience a loss of energy during the day?

   Yes  No  Occasional

 

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

   Lose Weight  Gain Weight  Maintain Weight

 

6. Approximately how much weight in pounds do you/they need to lose?

       You        

       Family           

      Friends          

 

7 Have you tried diet programs in the past?

 Yes  No

Which ones?   

 

8. Do you eat a variety of health foods from the basic food groups every day?

 Yes  No

 

9. If no to 8, why not?

 Not enough time for shopping/preparation  Too Expensive  Too Complicated

 

10. Do you currently suffer from any health or medical problems?

 Yes  No

     If yes, list them.  

 

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

 Yes  No

 

12. Would you prefer further information to be sent to your home or e-mail address?

 Yes  No

 

13. Would you like samples of products to be sent to your home free of cost?

 Yes  No

 

14. If you answered yes to 11, 12 and 13 please fill out the section below.

Full Name             

Mailing Address   

Home Phone No. 

Occupation            

E-mail address    

 

15. Is there anyone else you know who would take part in this survey?

Name                                                                                                             E-mail Address

                                         

                                         

                                       

Thank you for participating in this survey. Please submit by clicking Send. Please be sure to participate in the Outer Nutrition Survey as well.