Your Lifestyle Questionnaire

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1. If you had a 90day health goal, what would it be? *

2. Please tick any of the following diet related health concerns in your family / household? *

How soon would you like to stop or slow down the progression of the above mentioned health concerns which often develop undiagnosed until they have progressed?

3. What would be your biggest health concern in the future? *

4. Do you have Medical Aid? *

How much do you spend per month for your household?

5. How much do you spend on Vitamins / Supplements weekly? *

6. Are you trying to eat healthier? *

What are you doing to eat healthier?

What do you eat the most in your household? *

How much do you spend on food shopping for your household every week / month including eating out?

7. Do you enjoy preparing and cooking meals? *

8. List in order your most frequent cooking style? *

	Grilling	Frying	Roasting	Steaming	Boiling	Microwave
1	1 Grilling	1 Frying	1 Roasting	1 Steaming	1 Boiling	1 Microwave
2	2 Grilling	2 Frying	2 Roasting	2 Steaming	2 Boiling	2 Microwave
3	3 Grilling	3 Frying	3 Roasting	3 Steaming	3 Boiling	3 Microwave
4	4 Grilling	4 Frying	4 Roasting	4 Steaming	4 Boiling	4 Microwave
5	5 Grilling	5 Frying	5 Roasting	5 Steaming	5 Boiling	5 Microwave
6	6 Grilling	6 Frying	6 Roasting	6 Steaming	6 Boiling	6 Microwave

9. How important is eliminating the following from your meals? *

	Very	Fairly	Not important
Oils	Oils Very	Oils Fairly	Oils Not important
Fats	Fats Very	Fats Fairly	Fats Not important
Greases	Greases Very	Greases Fairly	Greases Not important
Salts	Salts Very	Salts Fairly	Salts Not important
Sugars	Sugars Very	Sugars Fairly	Sugars Not important
Processed Spices with animal products	Processed Spices with animal products Very	Processed Spices with animal products Fairly	Processed Spices with animal products Not important

10. Our Consultation Fee is US$50. Can you afford this?

11. Our meeting will be via Zoom. Do you have the Zoom App? *

Which day and time is best for you?

12. How did you know about Simba's Foods? If you received a flyer, please write the booking code at the bottom of the flyer. *

13. Your contact details: *

First name	*
Last name	*
E-mail	*
Tel	*
Address	*
How many Adults (over 18yrs) & Kids are in your household	*
What do you do for a living?	*