Questionnaire
1.  What is your current height and weight?
17.   Do you have a hard time stopping once you
start eating carb foods like starches or sweets?
Yes
No
2.  What is your ultimate goal weight?
18.  Do you get tired or feel foggy in the
afternoon?
Yes
No
3.  When you feel stressed, is your first instinct to eat?
19.  Do you find yourself searching for a sugar,
starch or caffeine fix in the afternoon?
Yes
No
4.  Do you frequently crave high-carb foods (sweets, pasta,
bread, etc)?
Yes
No
20.  How often do you eat out?
No
Yes
5.  If you stop eating carbs, do you experience carbohydrate
withdrawal symptoms, including headaches, irritability,
mood swings, trouble sleeping and anxiety?
21.  List your three favorite fast food
restaurants:
Yes
No
6.  List your five favorite foods:
22.   How often, per week, do you consumer
alcohol?
7.  At what time(s) of day are you most hungry?
In the morning
In the middle of the day
In the evening
In the afternoon
8.  List your top five favorite snacks?
23.   How many drinks do you have at a time
on average?
24.  Have you ever been diagnosed with an
eating disorder?  If yes, what diagnosis and
when.
9.  Do you drink soda?  
Yes
No
No
Yes
10.  Please list your favorite soda and about
how many sodas you have per day.
11.  Do you snack at night?
25.  Do you feel like you eat compulsively or
binge?
Yes
No
No
Yes
12.  How often do you exercise per week?
26.  What diets have you tried in the past?
13.  Do you have exercise equipment
available for use either at home or with a gym
membership?
27.  On which plan were you most
successful?
Yes
No
14.  Do you have any health issues?  If yes,
list below: (include high blood pressure or
cholesterol).
28.  How much, if any, of the weight did you
gain back?
No
Yes
29.  When you stopped your last diet, what
factor caused your break in success (ie.
hunger, lack of variety, cravings, stress).
15.  Would you rather feel hungry but eat food
you love or feel full but eat food that may not
be your first choice?
30.  What is the hardest part of losing weight
for you?
16.  What is the hardest part of losing weight
for you?
Please provider your name and email below.
Please consult your
physician before
starting any diet or
exercise program.
YOU MUST submit payment below before you can receive your plan.  
When returned to the survey, press submit.  Contact Angela at
angela@personalizeddietplans.com with questions.
Your answers are completely confidential.  Please answer the questions as honestly
as possible so that your plan can be accurate and comprehensive.
Make one time payment of $29.99 to receive
your diet plan today!