Health Evaluation Survey

Health Evaluation Survey

What is your body type? Thank you in advance for filling in the health evaluation survey. Don't worry the results information is Only posted on the follow up page and is not used for any other purpose. The form only shows a trend comparing your results with all those who have filled in the form. For your participation you will receive our ShapeWorks Customer Success Guide - free ($37.95 value)

Health Evaluation Survey

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Web Site URL

E-mail Address*
E-mail Address*

Country

Height Ft.-in (i.e.) 5-7

What is your Weight in pounds?

Which best describes your health?

Do you use any nutritional supplements? (vitamins, nutritional shakes, supplements)

	Yes
	No
	Herbal Alternatives

Supplements that you use

Are you taking any medications?

	Yes
	No
	Herbal Alternatives

How would you describe your lifestyle?

Do you participate in sports?

	Yes
	No
	Occasionally

Do you exercise regularly?

Do you suffer from any of these symptoms?

How many meals do you eat per day?

How much do you spend per day on breakfast?

How much do you spend per day on Lunch?

How much do you spend per day on mid-afternoon snack?

How much do you spend per day on dinner?

How much do you spend per day on mid-night snack?

How much do you spend per day on evening snack?

How much do you spend per day on food?

How much do you spend per day on beverages?

How many times do you eat out per month

What is the best way to lose weight?

Would you like to lose weight?

	Gain Weight
	At ideal weight
	Lose weight

How much weight would you like to lose, in pounds?

What diets have you tried in the past

Please enter the word that you see below.

See Also:
Weight Loss Tips 10 sensible weight loss tips that burn fat.
Sample Pack is also available as part of our ShapeWorks weight loss programs
Successful Weight Loss - Planning tips.
Herbal Enhancers - Fortify yourself everyday.
Herbal Nutrition Store All your herbal nutrition needs in one place.

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