FeelGoodLookGood4Life

1. Which of these words best describes your own lifestyle? * CalmActiveStressed

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

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

4. Do you experience a loss of vitality during the day? * YesNoOccasionally

5. Do you or does nay member of your family or friends need to examine their target weight? * YesNo

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

Family

Friends

7. Have you tried diet programmes in the past? * YesNo

Which ones?

8. Do you eat a variety of healthy foods from the five basic food groups everyday? * YesNo

9. If no, why not? * Not enough time for shopping/preparationToo expensiveToo complicated

10. Are you interested in learning about a nutritional programme to control weight while still eating many of the foods you like, without feeling hungry? * YesNo

11. When is the most suitable time to contact or telephone you? *

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

Name *

Occupation

Address

Telephone(Work)

Telephone(Home)