Questionnaire 1 | ALL ABOUT YOU ...

Your Details:
Name
Occupation
Address
Postcode
Tel. Work
Tel. Home
Email

Is there anyone else you know who would take part in this survey?
Name 1
Telephone

Name 2
Telephone

Question 1
Which of these words best describes your own lifestyle?

Calm
Active
Stressed

Question 2
Do you play sport or take regular exercise?

Yes
No

Question 3
Do you think you get 100% of the daily nutrition needed for good health?

Yes
No
Sometimes

Question 4
Do you take nutritional supplements (vitamins/minerals/protein)?

Daily
Never
Sometimes

Question 5
Do you experience a loss of vitality/energy during the day?

Yes
No
Occasionally

Question 6
Do you, or does any member of your family or friends need to lose, gain or maintain weight?

Lose weight
Maintain weight
Gain Weight
Can't say for certain

Question 7
Approximately how much weight do you/they need to lose?

You lbs
Family lbs lbs lbs
Friends lbs lbs lbs

Question 8
Have you tried diet programmes in the past?

Yes
No

Question 9
Do you eat a variety of healthy foods from the basic food groups every day?

Yes
No

Question 10
If not ... why not?

Not enough time for shopping/preparation
Too expensive
Too complicated

Question 11
Are you interested in learning about a nutritional programme to control weight while still eating the foods you like - without feeling hungry?

Yes
No

Question 12
When is the most suitable time to contact or telephone you?

Day

Time

RESET FORM

Please complete questionnaire 2 |
OUTER NUTRITION: [GO]