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 feel any health concerns you have are affected by or related to your diet?
6. To be your preferred weight, would you like to ... ?
Lose Weight Gain Weight Stay the same
7. How much weight would you like to ... Lose Gain
8. Have you tried weight management programs in the past?
Which ones?
9. Do you know the importance of knowing your body fat content?
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 one of our Wellness Consultants will contact you for your Total Wellness Evaluation.
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