Richer & Healthier

Richer & Healthier

Making the World Healthier

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A NEW YOU BEGINS HERE

Are you serious about weight management? If we could show you how you could not feel hungry, eat your favourite food, have lots of energy and still lose weight, would you be interested?

Please spare a couple of minutes to complete this survey. Our experienced wellness coach will contact you soon.

* Required Fields

* Your name:	* Your gender: Male Female

* Your telephone number:	* Your e-mail address:

* Your country:	* Your age:

* Your weight (kg):	* Your height (cm):

Your job:	Which of these words best describes your own lifestyle? Calm Active Stressed

Do you think you get 100% of the daily nutrition needed for good health? Yes No Sometimes	Do you take nutritional supplements (vitamins / minerals / proteins)? Yes No Sometimes

Do you experience a loss of energy during the day? Yes No Occasionally	Do you need to lose, gain or maintain weight? Lose weight Gain weight Maintain weight Can't say for certain

How much weight (kg) do you want to lose or gain?	Will your family or friends support you to lose or gain weight? Yes No Can't say for certain

Does any member of your family or friends need to lose, gain or maintain weight? Lose weight Gain weight Maintain weight Can't say for certain	Do you eat a variety of healthy food from the basic food groups everyday? Yes No

If not, why not? Not enough time for shopping / preparation Too expensive Too complicated	Are you interested in learning about a nutritional programme to control weight while still eating the food you like, without feeling hungry? Yes No

Have you tried any diet programmes in the past? Yes No	How much are you willing to spend on nutritional supplements (vitamins / minerals / proteins)?

Would you prefer further information to be sent to your home or office? Home Office	When is the most suitable time to contact you or telephone you? Morning Afternoon Evening