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Weight Control: Health and Lifestyle Questionnaire
Which of these words describe your lifestyle? Calm
Active
Stressed
Have you ever tried to lose weight before? yes
No
If Yes, what have you tried? Weight Watchers
Slimming World
Calorie Counting
Exercise
Other
What is your current weight?
What is your height?
Your Age?
Do you think you get 100% of the daily nutrition you need for good health? Yes
No
Do you take nutritional supplements e.g. Vitamins and Minerals? Yes
No
Sometimes
Do you experience a loss of energy during the day? Yes
No
Do you currently need to lose/gain weight? Yes
No
If Yes, how much weight would you like to lose?
Why do you want to lose/gain weight? Improve Health?
Improve Appearance?
Be able to be more active?
Be able to wear more fashionable clothes?
Other:
If Other, tell us why.
On a scale of one to ten, how serious are you about losing/gaining weight and gaining energy?
What is it that stops you from sticking do a weight control strategy? No Will Power
Lack of Support
Can't count calories
Haven't found something that works
Other:
If Other, tell us what it is that stops you:
Do you frequently get cravings for sweets, chocolate or "the munchies" Yes
No
Do you have any other health issues you need to consider e.g. skin, cellulite, digestion or medical problems
How regularly do you exercise Once a week
Twice a week
Three times a week
Every day
Other
If Other, add details
If we could show you a way to lose or gain weight and keep it like that for ever,while improving your health and energy levels, and eat your favourite foods. Would you be interested? Yes
No
What's your name?
Email address:
Day time Telephone No.
Evening Telephone No.
When is the most suitable time to call you?
Thank you for taking part in our on line Health and Lifestyle questionnaire, we'd love to help you, do you want to proceed
yes
no

 
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