Health & Wellness Survey
LD-Fitness
1. Which of these words best describes your own life style?
*
Calm
Active
Stressed
2. Do you believe that the foods you eat can affect your health?
*
Yes
No
Not Sure
3. Do you eat breakfast?
*
Yes
Sometimes
Never
4. Do you eat 3 meals per day?
*
Yes
Sometimes
Never
5. Do you ever participate in sport or exercise?
*
Daily
Weekly
Rarely
Never
6. Do you experience a loss of energy during the day?
*
Yes
No
Occasionally
7. Are you or anyone you know interested in improving your health or losing weight?
*
Yes
No
Not Sure
8. Have you tried diets or Weight Management programmes in the past?
*
No
Yes
A few Every one I can think of
Every one I can think of
9. Would you like a FREE consultation to help understand about long term health and weight management ?
*
Yes
No
How serious are you about losing weight?
1
2
3
4
5
6
7
8
9
10
Curious
Very serious
1 is Curious, 10 is Very serious
If "YES" please leave your details below and we will contact you within the next 48 hours.
Full Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
*
Where did you hear about us?
*
Please Select
Facebook
Leaflet Picked Up
Handed Leaflet outside
Handed Leaflet in "The Gym Group"
Email
How would you rate this survey
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2
3
4
5
Message
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