Information page
Information on your slimming objectives
Title:
Choose:
Mrs
Miss
Mr
Surname:
Name:
Address:
Town/Postcode:
Phone:
E-mail:
Age:
Do you have any children? If yes, how many?
Your height (in cm):
cm
Your current weight:
kg
What is your target weight?
kg
Do you have weight issues for a long time?
Choose:
Yes
No
If yes, since when?
Have you ever followed a diet?
Choose:
Yes
No
If yes, which ones?
Are you currently on a diet?
Choose:
Yes
No
If yes, which one?
Do you do any sport/exercise?
Choose:
Yes
No
If yes, which type of sport/exercise?
If yes how many hours/days per week?
Do you consider your diet to be balanced?
Choose:
Yes
No
If no, why?
You eat...
(Now touch Ctrl + Click to select several options)
Because you feel hungry
Out of habit
Because you feel like it
In a compulsive way
Would you like to add any further information:
Have you any questions regarding Nutricoachaustralia?
Are you a member of a gym?
Would you like to be contacted by e-mail or by telephone?
Choose:
E-mail:
Phone:
On receiving your questionnaire, we will get in touch with you in order to respond to all your questions.
The coach