This questionnaire has been designed to establish your personal requirements. Please answer all of the questions below by ticking the appropriate box.

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

Experienced consultants are available to offer advice by phone. Hard to contact? Never in? No landline number then call us on 01673 838 916. Best time to reach is between 1-9pm.

The way we work

1. Identify with you what your key challenges are

2. Suggest a recommended programme

3. Provide ongoing advice by phone and email as required

Over 18 over please, if under 18 please complete with assistance of parents.

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.Irregular meals or eat late? Please give details

8..Can you run through a typical daily diet:

Breakfast e.g. cereal/toast

Mid morning e.g. fruit, chocolate bar

Lunch

Mid afternoon

Dinner

After dinner

9.Do you smoke?

Yes No

10. Sweet tooth?

Like sugary foods/chocolate

Really like sugary snacks

Really, really like sugary snacks! (eg multiple choc bars)

Don't like sugary snacks

Other snack consumption

11. How much still water to you drink each day?

3+ litres

2+litres

1+ litre

odd glass

Fizzy drink consumption :

12.Any food groups you cant consume? Please give details

13.Any health challenges? IBS, Diabetes, Arthritis, sleep problems, high cholesterol, heart disease etc etc

14.Body shape/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 "apple" body type affects 20% of population)

Yes  No

Yes No

Do you find you are not content with just one biscuit, but take another, and another

Yes No

Yes No

16.What type of work do you do ie 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

Excess carbohydrates

Low energy

Don't know

Other (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?

0-4 weeks
4-8 weeks
8-12 weeks
3-6 months
6-12 months
ASAP - I'm serious and committed

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? (excl evening meal)

Less than £1.00 per day
£2.00                        
£3.00                                             
£4.00                         
£5.00

25.How 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?

1. Extremely serious              
2. Fairly serious                    
3. It doesn't really worry me   

31. How serious would you say you are about maintaining long term good health by looking after your body now?

1. Extremely serious              
2. Fairly serious                    
3. It doesn’t really worry me   

Information required:

Advice

I have questions that i need answering

Additional Information:

Name 

Telephone Evening 

Telephone Day

Mobile

Best time to call Telephone consultations between 9am -9 pm on landline telephones only Hard to contact, never in, no landline number? Phone us on 01673 838 916 at least 30 mins after completing the questionnaire. Best time to reach is between 1-9pm.

Please check your contact details or we cant help you!