Calm Active Stressed

2.Do you think you get 100% of the daily nutrition you 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 need to lose/gain/maintain weight?

Lose Gain Maintain

6.Approximately how much weight you / they need to lose (or gain/maintain)?

Lose upto 5 kgs Lose upto 10 kgs More Gain Maintain

7.Have you tried diet programs in the past?

Yes No

8.Do you eat a variety of healthy foodsfrom the basic food groups everyday?

Yes No

9.If No, Why not?

No Time Expensive Complicated

10.Are you interested in learning about a nutritional programto control weightstill eating foods you like?

Yes No

11.When is the most suitable time to telephone you / contact you??

Morning before 8.00A.M Forenoon Afternoon Evening Evening after 7.00 P.M

12.Please provide the following contact Particulars:

Contact_Name

MobileNumber

Resident­_City

Cont_E-Mail