Vitaline Questionnaire

By completing this questionnaire, Vitaline can access your metabolism and work out the correct diet plan for you. After submitting the information below, you will be able to join Vitaline and access your starter Cleanser diet immediately. It costs $49.95 for a four week slimming course with one-to-one counselling, encouragement and support, as often as you need it, from your own personal instructor.

The questionnaire is detailed but all the information is important in assessing your dietary needs. Please answer all the questions truthfully to enable Vitaline to supply you with the most suitable diet. We look forward to receiving your completed questionnaire.

It is important to weigh yourself accurately before you enrol. You will need to record your weight in pounds (lb) on the questionnaire. For help with your calculation, one stone is 14lb, and 1kg is 2.2lb. e.g. 10 stone = 140lb (10 x 14) 65kg = 143lb (65 x 2.2)

Please complete all the questions ensuring your e-mail address is accurate in order for us to reply speedily.

1. Contact Details. First Name* Family Surname* Sex Female Male Age* Height (ft/in)* 4 5 6 ft 0 1 2 3 4 5 6 7 8 9 10 11 in   Present weight (lb)* lb Address* Post/Zip Code* Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi C'ôte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Isla Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying I Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Telephone E-mail*

2. Health & Lifestyle. Your answers to the following questions will affect your resultant metabolic rate. Please answer them carefully. Are you a PCOS sufferer? Y N Are you a vegetarian? Y N Do you have a medical condition? Y N If yes, please choose from: heart conditionhigh blood pressurelow blood pressurestrokediabetesarthritisirritable bowel syndromecancerother If other, please enter Are you a diabetic on injections? Y N Do you have any allergies? Y N How many times have you had general anaesthetic or surgery? Have you suffered any bereavements in the family in the last three years? Please include family pets. Y N Have you ever had teeth removed or had other dental work including fillings? Y N How many pregnancies have you had? Are you at present on:   Hormone Replacement Therapy Y N The "Pill" Y N The Injection "Pill" Y N Do you smoke? Y N Have you tried to stop smoking? Y N If yes, how many times? Have you in the past three years been on medication prescribed to you by your doctor? Y N Have you experienced divorce, separation or troubled relationships? Y N Have you experienced other severe traumas or upsets in the last three years? Y N Have you, or has any person close to you, been made redundant? Y N Have you moved house in the last three years? Y N Do you have an active job? Y N Do you experience stress in your work or social life? Y N Have you been responsible for an elderly, or close, member of your family for any length of time? Y N Are you retired? Y N Has any of your children or any person close to you been ill for long periods of time? Y N Do you suffer from depression? Y N