Weight Loss/Nutrition Personalised Programme
"Miss meals, really like sugary foods, sensitive to carbs. ,energy levels etc??.."
This questionnaire has been designed to establish your personal requirements. Please answer all of the questions below by ticking the appropriate box. Serious enquiries only please from over 18s. If under 18 please ask your parents to complete.
What are your challenges? Feeling hungry, tired, eating too many or too few calories, not enough protein, too many carbs and wrong kinds of carbs, not drinking enough water, etc Suggest you these links before completing the questionnaire. Are you getting the right protein intake? What are your key challenges?
Experienced consultants are available to offer one to one advice.
This way we get results...and have hundreds of thousands of thank you letters on file across 58 countries.
1.Which of these 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 (vitamins/minerals/proteins)
Daily Never Sometimes
4.Do you experience a loss of vitality during the day? Give details
YesNo Occasionally
5. Do you eat 3 meals a day?
Yes No
.6.If no, which meal/meals do you miss.
7.Can you run through a typical daily diet:
7a.Irregular meals or eat late? Please give details
8.Do you smoke?
9. Sweet tooth?
Like sugary foods/chocolate
Really like sugary snacks
Really, really like sugary snacks! (e.g. multiple choc bars)
Don't like sugary snacks
Other snack consumption
10. How much still water to you drink each day?
3+ litres
2+litres
1+ litre
odd glass
Fizzy drink consumption? :
11.Any food groups you cant consume? Please give details
12.Any health challenges? IBS, Diabetes, Arthritis, sleep problems, high cholesterol, heart disease etc etc
13.Body shape (click on link to see illustrations)
Lower
Upper
Proportionate
14.Sensitivity to carbohydrates
You have more than 10lbs to lose and you tend to carry your excess weight around your middle rather than all over? (i.e. an "upper" body type affects 20% of population)
Are you sensitive to excessive carbohydrate intake? Do you crave bread, pasta, rice, snack foods and sweet treats
Do you find you are not content with just one biscuit, but take another, and another
Do you feel tired after carbohydrate- rich meals (bread, pasta, rice, potatoes?
Would you describe carbohydrate--rich foods as a "weakness" in your diet?
15. You have less than 10lbs to lose but those stubborn inches are on hips, thighs & bum
16.What type of work do you do i.e. sedentary, active, at home
17. Do you know your fat content?
18. How have you tried to lose weight before? You may select more than one
Counting calories or points
Low fat diets
Low carb / high protein
Meal replacement drinks
Other (please specify)
19.Your obstacles to weight loss
Snacking
Slow metabolism
Poor nutrition through dieting
Low energy
Don't know
Other challenges (please specify).
20. What has caused your weight gain? If known
21.What is your weight loss goal?
0-3 lbs 4-7 lbs 8-14 lbs 14-28 lbs 28 lbs +
22..When are you looking to lose the weight by?
23.Why do you want to lose weight?
To look good To have more self-confidence For health reasons I'm going on holiday I'm attending a special event Other (please specify)
24.How much do you spend on breakfast, lunch, snacks and fizzy drinks? (exclude evening meal)
Less than £1.00 per day £2.00 £3.00 £4.00 £5.00
25How much are you prepared to spend per day to achieve your goal?
Less than £1.00 £2.00 "I couldn't believe the money I saved on my food bill £3.00 using this programme. I saved money on lunch and snacks and soft drinks" £4.00 Jenny Talkington, Wiltshire £5.00
26.How old are you?
27.How tall are you?
28.Approx weight?
29.What is your ideal goal ?
30.How serious would you say you are about your losing weight?
31. How serious would you say you are about maintaining long term good health by looking after your body now?
32. Would you benefit from weekly advice by phone or email?
Yes
No
33. Information required e.g. I have questions I need answering/ general advice /personalised programme.
34. Which areas of interest?:
Increasing nutrient and protein intake. Feed the body not starve it
Thermojetics, supporting the metabolism
Herbal Supplements -better absorption of nutrients, detox, cleansing
Boosting vitality
Name
Telephone Evening
Telephone Day
Email
How did you make contact with us? did some one refer you, advertising, search engine, poster etc
Best time to call Telephone consultations between 9am -9 pm on landline telephones. And on Saturday between 10-4pm. If your "hard to contact" or don't have a landline number call us on 01932 889236 .Contact us at least 30 mins after completing the questionnaire.
Which part of the country are you from? County or nearest large town?
Please check your contact details or we cant help you! Please check that you have completed information required box.
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