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   Diet Questionnaire

After you purchase our e-book, "Why Weight? Diet Successfully Now!" , use this form so that we may provide you with a personalized diet strategy.

Items in red are required.

First Name:        Last Name:

Address :

City:  State:   Zip:

Height: Weight: Age:

Are you:   Male   Female


E-mail Address:

Please reenter your e-mail address:

How did you learn about our site?

What are your weight goals?

In what way will losing weight change your life?

Have you been gaining or losing weight lately?

Are you willing to make some changes in your diet to lose weight?

How many hours do you spend doing the following activities:


In very-light activity? (sitting, standing still, shopping, driving)

In light activity? (vacuuming, cooking, auto repair, manufacturing line, golf, bowling)

In moderate activity? (washing floors, carpentry, aerobics, hiking, tennis, jogging)

In heavy activity? (moving furniture, construction, boxing, running, skiing)

Do you cook for yourself?

What do you normally eat for the following meals:



Afternoon Snack?


Bedtime Snack?

What is are your favorite foods:






How much do you drink in a day?

How much alcohol do you drink in a week?

Do you eat when you are emotionally sad, angry, bored, etc...?

What time do you have dinner?

Do you exercise regularly?

What difficulties do you have dieting?

What foods do you crave?

Describe your level of activity.

Describe your weight history?

Where you heavy as a child?

Why do you want to lose weight?

What is your goal?

Has your doctor given you any activity or food restrictions? If yes please explain.


Please read and type your name in below.

I understand that is a support and educational service and is not qualified to give medical advice. I understand everyone should consult a physician before starting any diet plan and I shall seek a physicians help if I do not feel well.

By typing your name below you agree you have read and understand the above statements.

Type name here:


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