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SWANLAND NUTRITION
HEALTH SURVEY 💚
*
1.
How many days per week do you start with a breakfast?
(Required.)
0
1
2
3
4
5
6
7
2.
If you don’t have breakfast every day, what’s the reason?
No time
Not hungry
Less calories
Other (please specify)
*
3.
What kind of breakfast did you have this morning?
(Required.)
*
4.
During the day, do you have a loss of energy?
(Required.)
Never
Mid morning
Mid afternoon
Evening
Several times per day
*
5.
Are you satisfied with your weight?
(Required.)
Yes
No
Weight I would like to lose or gain?
*
6.
Do you do sports or exercises?
(Required.)
No
Yes 1 x week
Yes 2 x week
Yes 3 x week
Yes 4 x week
Other (please specify)
7.
Would you like to know more about an easy, healthy breakfast?
Yes
No
*
8.
Would you like to have a free Wellness Evaluation to know your muscle mass, water and fat %?
(Required.)
Yes
No
*
9.
On a scale of 1 to 10
(1 being ‘not quite ready yet’ and 10 being ‘Absolutely Ready to Roll’)
How committed do you feel to transforming your nutrition habits for a healthier lifestyle? 💚
(Required.)
*
10.
Mobile Number
(Required.)