Your Lifestyle Questionnaire

1. Are you trying to eat healthier?

Yes
No

2. How much do you spend on Vitamins / Supplements?

3. Do you enjoy preparing and cooking meals?

Yes
No

How much do you spend on food shopping for your household every week?

How much do you spend per week eating out on takeaways / restaurants?

4. 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

5. 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

6. Would you agree that eating food prepared and cooked through the above methods can affect how you LOOK, how you FEEL and how long you LIVE?

Yes
No

How much do you spend per month on Medical Aid for your household?

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

8. Inasmuch as your health is important, it is inasmuch important as to how you source, how you prepare, how you cook and where you cook your food. Would you agree?

Yes
No

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

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

11. Would you be interested in attending our ONLINE CLASSES and learn how to cook for a CURE, eliminating the root causes of the above-mentioned diseases?

Yes
No

Do you have access to WiFi?

12. What time is best for you during the week?
6pm start is only for SUNDAYS *

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

14. Please provide us with your contact details: *

First name	*
Last name	*
E-mail	*
Tel	*
Address	*
How many Adults (over 18yrs) & Kids are in your household	*

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