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Slimming Health Assessment

Please note all fields are required.

   

Contact Information.

Title  
First Name  
Last Name  
E-mail Address  
Confirm E-mail Address  
Contact Number  
Prefered time and day for contact:    
Age:   years months
Gender:  
Height:   feet inches
Weight:   st lbs
Are you a Vegetarian?  

Please Answer the following

1) Do you find it hard to lose weight?
Yes No
2) Do you tend to store weight around your stomach?
Yes No
3) Do you feel like eating even if you are not hungry?
Yes No
4) Do you have sugar based foods 3-4 times/day?
Yes No
5) Do you have a sedentary lifestyle?
Yes No
6) Do you suffer from indigestion or heartburn?
Yes No
7) Do you suffer from bloating?
Yes No
8) Do you suffer from wind & flatulence?
Yes No
9) Do you suffer from constipation?
Yes No
10) Do you suffer from loose bowels?
Yes No
11) Do you suffer from arthritis?
Yes No
12) Do you suffer from any heart disease or condition? Are you on medication? 
Yes No
13) Do you suffer from high cholesterol levels? Are you on medication? 
Yes No
14) Do you suffer from high blood pressure? Are you on medication? 
Yes No
15) Do you suffer from diabetes?
Yes No
16) Do you suffer from thyroid problems?
Yes No
17) Do you exercise regularly? 
Yes No
18) Have you heard about detoxification?
Yes No
19) Have you ever used any supplement for weight management?
Yes No
20) Will you be interested in information regarding detoxification and weight management?
Yes No

Please Answer the following

1) On average how many serves of fruits do you have everyday? (This can include fresh, frozen and tinned fruit and 1x 250ml glass of pure fruit juice. A serve is 1 large piece of fruit – apple, peach, and 2 small pieces of fruit –small plums or 1 cup of berries or grapes.)
 I never eat fruit.
Less than 1 serving every day
1-2 servings
3-4 servings
more than 5 servings
   
2) On average how many serves of vegetables do you have every day? (This can include fresh, frozen, tinned vegetables. but no potatoes of any kind. serving is a fist sized amount or a cup of leafy greens.
 I never eat vegetables.
Less than 1 serving every day
1-2 servings
3-4 servings
more than 5 servings
   
3) On average how many serves of dairy food do you have every day? (This can include 250ml glass of milk, a pot of yogurt or a chunk of cheese. If you use calcium enriched Soya or rice milk)
 I never eat.
Less than 1 serving every day
1-2 servings
3-4 servings
more than 5 servings
   
4) On average how many glasses of water do you have every day?
 I never drink.
Less than 1 glass every day
1-2 glasses
3-4 glasses
more than 5 glasses
   
5) On average how many cups of coffee/tea do you have every day? ( do not include herbal or decaffeinated drinks)
 I never drink.
Less than 1 cup every day
1-2 cups
3-4 cups
more than 5 cups
   
6) On average how many serves of sugar based foods do you have every day? (This can include chocolate, biscuits, puddings, desserts, cakes, pastries, sweets).
 I never eat.
Few times a week
1-2 times a week
3-4 times a week
more than 5 times a week
   
7) On average how many cups of sugar do you add to your drinks every day
I never take sugar.
Less than 1 t/spoon every day
1-2 t/spoons
3-4 t/spoons
more than 5 t/spoons.

Ensure that you have answered all the questions correctly before you click the SUBMIT button.


Within seven days, we will contact you on the above mentioned contact numbers at the preferred time and day specified by you. Our health professionals will provide you with expert guidance and help you find answers to all your slimming related problems.
 
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