Health Survey

Health and Lifestyle Survey
“Hello. Can you spare me just two minutes? I am conducting a survey about Health and Lifestyle”
1	Which of these words best describes your own lifestyle?
2	Do you think you get 100% of the daily nutrition for good health?
3	Do you take nutritional supplements (Vitamins/minerals/proteins)?
4	Do you experience a loss of vitality during the day?
5	Do you, or does any member of your family or friends need to lose, gain or maintain weight?
6	Approximately how much weight do you need to lose?	Kg
7	Have you tried diet programs in the past?
8	Do you eat a variety of healthy food from the basic food groups everyday?
9	If no, why not?
10	Are you interested in learning about nutritional program
11	When is the most suitable time to contact you? Day Time
12	Would you prefer further information to be sent to your home or office?

Name:	Occupation:
Address
City:	Country:
Tel:	Mobile: Email:
Is there anyone else you know who would take part in this survey?
Name:	Email:
Name:	Email:
Name:	Email:
Name:	Email: