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Consumer Health Survey
Response-O-Matic Form

 

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Your comments are appreciated!

Just complete this form. Click on Submit when ready to send.

 

Want to be slim and healthy? Take the test! We can tailor a nutrition programme to suit your needs, FREE!

Your name:

Email address:

Would you like to:

Lose weight
Gain Weight
Build lean muscle
Improve your health

What is your 'Goal Weight'?

 

Do you...?

Eat a variety of healthy foods from the basic food groups?
Eat take away/ convenience (tinned, prepackaged) food more than once a week?
Experience a loss of stamina during the day?
Work/live in a high stress environment?
Suffer from skin problems, such as psoriasis, acne, dermatitis?

What have you tried before?

Weight loss clubs
Exercise
Surgery
Dieting

 

How much weight would you like to lose/gain?

 

Do you have any other health concerns?