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First Name

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1. What is your age?

2. Where do you live?

3. Are you married?YesNo

4. Do you have children?YesNo

5. If yes, what are their ages?

6. Are you happy with the size and shape of your body?YesNo

7. What dress size are you?681012141618+

8. What is your target dress size?681012141618+I have no target I'm happy with my size

9. How much weight would you like to lose?5 pounds10 pounds15 pounds20 poundsOver 20 poundsI’m happy with my weight

10. How many diets have you been on in your life?I have never been on a diet1-55-1010-2020-3030 or more

11. How many diets did you try in 2016?I didn’t try any dietsI don’t like the word ‘diet’Between 1 and 3Between 3 and 55 or more

12. How many times did you try to lose weight in 2016?1-1010-2020-3030 or more

13. What is the main thing stopping you from sticking to a new weight loss diet?TirednessHungerBoredomFeeling deprivedDoesn’t fit with my lifeThe food is too complicatedAll of the above

14. Do you hate the word diet?YesNo

15. Do you prefer 'healthy eating'?YesNo

16. If a diet could promise you one thing AS WELL AS weight loss that stayed off what would that be (please choose one)?More energyAnti-agingBetter moodHealthy skin

17. What do you want most from a healthy eating plan, please prioritise with one being your most desired and six being your least

More energy to do all the things I need to do without tiredness 123456
Better mood so I feel happier throughout the day 123456
Weight loss that stays off 123456
Glowing skin that needs little make-up 123456
Anti-aging of face and body 123456
Disease prevention 123456

18. Do you exercise regularly, that is three or more times a week?YesNo

19. What kind of exercise do you do?RunningYogaBoxing and martial artsCycling or spinWalkingSwimmingCombination of the aboveOther (please specify below)

20. What stops you exercising regularly?Not enough timeI’m too tiredI get boredCan’t afford a gym membershipI travel all the timeOther (please specify below)

I would like to receive the Healthista newsletter Yes