Our 2 minute survey

This questionnaire has been designed to establish your personal requirements. Please answer all of the questions below by ticking the appropriate box.

This is not a diet plan, nor slimming pills, instead weight management through outstanding herbal based nutrition. "More to losing weight than counting calories"

Over 18 over please, if under 18 please complete with assistance of parents.

Please answer all of the questions below by ticking the appropriate box.

1.Do you want to lose weight right now?

Yes   No

2. Why do you want to lose weight / is there a specific reason?

(holiday, medical reasons, birthday, ........)

3. What kind of weight loss programs have you tried?

Counting calories or points

Low fat diets

Low carb / high protein

Meal replacement drinks

Other (please specify)

3a If you have tried losing weight before - did the plans work for you?

4. How old are you?

5. How tall are you?

6. Approx weight?

7. How much weight would you like to lose?

0-3 lbs
4-7 lbs
8-14 lbs
14-28 lbs
28 lbs +

8. When are you looking to lose the weight by?

9. Do you eat 3 meals a day?

Yes No

10. If no, which meal/meals do you miss.

11. Do you tend to get hungry throughout the day?

 Yes No

12. Do you experience a loss of vitality during the day? Give details

YesNo Occasionally

13. Any health challenges? IBS, Diabetes, Arthritis, sleep problems, high cholesterol, heart disease etc etc.  Are you on any medication?

14. Are you willing to try something new?

Yes
No    

15. Additional information

Name  

Email 

Telephone evening  

Telephone day   

Please call me, the best time and day is   

Do you prefer email or telephone contact?

Telephone consultations between 9am -9 pm on landline telephones

Please note:  This is a serious weight loss programme not a quick fix from the high street!  Backed up with 1.5 million thank you letters on file and money back guarantee

Please check that your contact details are correct before submitting this form.