H1 Headings

1. How would you describe your lifestyle?

Calm Active Stressed

What sort of work do you do?

2. Do you think you receive balanced nutrition daily from the foods you eat?

Yes No

3. Do you take nutritional supplements?

Daily Never Sometimes

4. Do you suffer a loss of energy or stamina during the day?

Yes No Sometimes

If yes, at what time?

5. Do you think that your diet affects the way that you feel daily and your overall health long term?

Yes No Not sure

6. To be your ideal weight, do you need to...?

Lose Weight Gain Weight Maintain current weight

7. How much weight would you like to...?

Lose Gain

8. Have you tried seriously to lose or gain weight in the past?

Yes No

If yes, how?

9. Do you know the importance of knowing your Body Mass Index (BMI)?

Yes No

10. What is your level of exercise?

Athletic Regular Occasional Never

Thank you for completing our quick survey. By submitting this form you acknowledge that we will contact you for your Total Wellness Evaluation and arrange your free product sample.

When would be the best time to call to arrange an appointment?

Daytime Evening

Thank you!