Energy Review

Your Energy Level Indicators

Please answer the following questions and once we have received your responses we will contact you to arrange your free 20 minute phone consultation

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* 1. Please enter your personal details

Name:

Email:

Phone Number:

Age

Gender

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* 2. To what extent do the following phrases apply to you?

	Always	Sometimes	Rarely	Never
I am wide awake within 15 minutes of getting up	I am wide awake within 15 minutes of getting up Always	I am wide awake within 15 minutes of getting up Sometimes	I am wide awake within 15 minutes of getting up Rarely	I am wide awake within 15 minutes of getting up Never
I need tea, coffee or something sweet to get me going in the morning	I need tea, coffee or something sweet to get me going in the morning Always	I need tea, coffee or something sweet to get me going in the morning Sometimes	I need tea, coffee or something sweet to get me going in the morning Rarely	I need tea, coffee or something sweet to get me going in the morning Never
I crave chocolate, sweet foods, bread, cereal or pasta	I crave chocolate, sweet foods, bread, cereal or pasta Always	I crave chocolate, sweet foods, bread, cereal or pasta Sometimes	I crave chocolate, sweet foods, bread, cereal or pasta Rarely	I crave chocolate, sweet foods, bread, cereal or pasta Never
I have energy slumps during the day or after meals	I have energy slumps during the day or after meals Always	I have energy slumps during the day or after meals Sometimes	I have energy slumps during the day or after meals Rarely	I have energy slumps during the day or after meals Never
I have mood swings	I have mood swings Always	I have mood swings Sometimes	I have mood swings Rarely	I have mood swings Never
I have difficulty concentrating	I have difficulty concentrating Always	I have difficulty concentrating Sometimes	I have difficulty concentrating Rarely	I have difficulty concentrating Never
I get dizzy or irritable if I go 6 hours without food	I get dizzy or irritable if I go 6 hours without food Always	I get dizzy or irritable if I go 6 hours without food Sometimes	I get dizzy or irritable if I go 6 hours without food Rarely	I get dizzy or irritable if I go 6 hours without food Never
I overreact to stress	I overreact to stress Always	I overreact to stress Sometimes	I overreact to stress Rarely	I overreact to stress Never
My energy is really low	My energy is really low Always	My energy is really low Sometimes	My energy is really low Rarely	My energy is really low Never
I feel too tired to exercise	I feel too tired to exercise Always	I feel too tired to exercise Sometimes	I feel too tired to exercise Rarely	I feel too tired to exercise Never

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* 3. Please describe how well you sleep. If your sleep is disturbed please let us state whether this is related to someone else (husband, child).

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* 4. What is your weight?

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* 5. What is your height?

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* 6. How many glasses of water do you drink each day?

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* 7. How many cups of tea or coffee do you drink each day? Specify which kind e.g. decaf, coffee shop, herbal

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* 8. On an average day how many portions of fruit do you eat?

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* 9. On an average day how many portions of vegetables do you eat?