Create Improved Genral Health & Vitality Profile

1. Country?*

2. Gender?*

MaleFemale

3.

First Name*

Last Name

Date of Birth (dd/mm/yyyy)*

Email Address

Re-Type Email Address

Phone Number (inc. area code)*

4. Best Day To Contact?*

5. Best Time To Contact?*

6. Do you have any health concerns? (e.g. Diabetes, high blood pressure or history of heart problems)

7. How would you describe your health and energy levels?*

8. Why do you think you are no longer achieving your desired health & energy levels?

9. What have you tried before to improve your health and energy levels? (please list all prior programmes)

10. Why do you think it/they didn't work?

11. Which best describes your current diet?*

12. How many servings of fruit and vegetables do you eat daily?*

13. How many times per week do you exercise?*

14. Why are you concerned about your health and vitality now?

	Health problems
	My Doctor told me my health needs to improve
	My partner/relatives are pushing me to take care of my health
	No special reason
	Just think it would be a good
	Other, please specify

15. On a scale of 1-10 with 10 being the most serious, how serious are you about improving your health & energy levels?*

16. How quickly do you expect that you will be able to achieve the optimum health you desire?*

17. Are there any other areas of your health that you would like to improve?

18. Where did you hear about us?

19. I certify that I am 18 years or older*

Yes

Create Improved General Health & Vitality Profile