Home : : Beyond Weight Management : : Testimonials : : Survey : : Contact

Health & Nutrition Survey

1. How would you describe your lifestyle?

Calm

Active

Stressed

2. Do you believe there's a connection between the food you eat and the level of your health?

Yes

Not sure

3. How often do you have take-away meals or frozen dinners?

Frequently

Sometimes

Seldom

4. Do you think you get 100% of the daily nutrition that your body needs for good health?

Everyday

Sometimes

Rarely

5. Do you take nutritional supplements?
(vitamins/ minerals/ proteins)

Yes

Sometimes

5A (Yes) Great, so which ones do you take?

5B. Have you noticed any difference? What have you noticed?

6. Do you experience a drop in stamina or energy during the day?

Yes

Occasionally

6A. Is there a regular pattern, what time would that be?

7. Do you, or anyone close to you, have any of the following?

Asthma

Migraines

Allergies

Ulcers

Arthritis

Digestive Problems

High Cholesterol

High Blood Pressure

Sinus Problems

Diabetes

Hormone Imbalance (Women only)

8. To be your ideal weight, would you like to:

Lose weight

Gain weight

Stay the same

8A. How much would you like to lose/gain?
8B. What have you tried before to lose/gain weight?

8C. Why wasn’t it successful?

9. Do you have any of these lifestyle factors that may impact on your health?

Smoking

Too much alcohol

Not enough sleep

Not enough exercise

Less than 2 litres water per day

10. How would you rate your overall current state of health?

Above Average

Average

Below Average

If you could trial a product that

gave you heaps of energy all day long,
(easily lose/gain weight while still eating the foods you like)
give you 100% nutrition every day for optimum health
& help with any problems and feel better

would you like to find out more about it?

If Yes please send this email with a contact number or phone me and we can discuss your circumstances in confidence.

Your Name	Your Email
Gender:
Contact Phone	Country
How did you hear about this website? eg. web search, name of referrer etc.

I look forward to speaking with you
Geoff Browne