Health and Lifestyle Survey
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 (vitamins/minerals/proteins)?
Daily Never Sometimes
4. Do you experience a loss of energy during the day?
Yes No Occasionally
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 Can’t say for certain
6. Approximately how much weight do you/they need to lose?
You lbs
Family lbs
Friends lbs
7. Have you tried diet programs in the past? Which Ones:
Yes No
8. Do you eat a variety of healthy foods from the basic food groups everyday?
Yes No If no, why not? Not enough time for shopping/preparation Too complicated Too expensive
9. Are you interested in learning about a nutritional program to control weight while still eating the foods you like, without feeling hungry?
Yes No