WEALTHSUCCESS1ST - HEALTH & NUTRITION QUESTIONNAIRE
Which of these words best describes your lifestyle?
q CALM
q ACTIVE
q STRESSED
Do you believe that the foods that you eat can affect your health?
q YES
q NO
q DON’T KNOW
Do you think you get 100% of the daily nutrition you need for good health.
q YES
q NO
q SOMETIMES
Do you eat 3 times a day?
q YES
q NO
q OCCASIONALLY
Do you take nutritional supplements such as vitamins or minerals?
q DAILY
q NEVER
q SOMETIMES
Do you ever find you run out of energy during the day?
q YES
q NO
q OCCASIONALLY
Do you ever participate in sports or exercise?
q EVERY DAY
q 1-3 TIMES / WEEK
q RARELY
Do you or any of your family or friends need to lose or indeed gain weight?
q LOSE
q GAIN
Approximately how much do they/you need to lose/gain ______________lb /kgs/stones?
On a scale of 1 –10, how serious are you/they about wanting to lose weight?
1 2 3 4 5 6 7 8 9 10
What would it take to move you to a more serious level?
………………………………………
Do you eat a variety of healthy foods from the basic food groups every day?
q YES
q NO
How much do you spend each day on food for yourself?
o $200 o $400 o $500 o $600
Thank you for your time, which of the following would you like to receive FREE information on?
q WEIGHT LOSS
q WEIGHT GAIN
q SPORTS NUTRITION
q GENERAL GOOD HEALTH
q SKIN CARE
Do you know anyone with an interest in health, nutrition, or skincare who might like to earn an extra income working from home, without risking your full time income?
q YES, I would!
q YES, I know people
q NO
NAME: ____________________________
TEL: ____________________________
EMAIL: ____________________________
ADDRESS:
If yes, when is the best time to contact you?
q MORNING
q AFTERNOON
q EVENING
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