Lifestyle Questionnaire Order Number PERSONAL STRATEGY QUESTIONNAIRE Please complete this questionnaire as honestly as you can. There are no right or wrong answers, and everything you share will be kept strictly confidential. Once you have completed it, please click “Submit” so we can discuss your next steps. First Name * Last Name * Date of Birth Phone Number Email Address * Street Address Suburb Post Code Are you currently experiencing any health issues, pain, uncomfortable physical symptoms, or mood problems? * Yes No What aspects of your health would you like to focus on? (Select all that apply) * Easier weight loss Eliminate water retention and bloating Smoother, clearer skin and brighter eyes Waking up well-rested and refreshed Enhanced concentration and sharper mind Clearer sinuses - not blocking up Eliminate bags or dark circles under my eyes Better digestion and bowel movements Fewer aches and pains Improve my immune system Fewer infections Alleviate symptoms of female PMS Other Take an inventory of your usual grocery shopping basket How likely are you to buy pastries, cakes, biscuits, ice cream, desserts, or other sugary snacks? (1 being unlikely and 5 being highly likely) * 1 2 3 4 5 How likely are you to buy crisps, cheese crackers, salted peanuts, or other fatty snacks? (1 being unlikely and 5 being highly likely) * 1 2 3 4 5 How likely are you to buy ready meals, frozen burgers, frozen pizzas, hot dogs, sausages, cured meats, or other fast foods? (1 being unlikely and 5 being highly likely) * 1 2 3 4 5 If someone told you that you need to give away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your detox goals, would you do it? * Yes No Have you worked with a nutritional advisor in the past? * Yes No If yes, please specify the type of provider and the results you obtained or did not obtain Thank you for completing our questionnaire! We look forward to reading your responses and connecting with you to arrange the next phase of the process! Please click the submit button below antispam EMAIL US info@jkwellnessnutrition.com FOLLOW US
