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  1. Surveys
  2. 2013
  3. April
  4. L
  5. Lifestyle questionnaire
0%
Exit Survey
 
 
How often do you eat per day?
 
Twice
 
Thrice
 
four times
 
Six times
 
Other
 
 
 
 
Of what does your breakfast consist?
 
Cereal - mainly carbs
 
A good protein only (eggs etc.)
 
Nothing
 
Oats
 
Other
 
 
 
 
When does your day start?
 
07:00
 
08:00
 
09:00
 
Other
 
 
 
 
When does your day end? (sleep)
 
20:00
 
22:00
 
23:00
 
Other
 
 
 
 
How often do you exercise for - one hour - per week?
 
(1-2)x 1 hour sessions per week
 
(2-3)x 1 hour sessions per week
 
(3-4)x 1 hour sessions per week
 
(4-5)x 1 hour sessions per week
 
Other
 
 
 
 
What is your physical goal (body)?
 
Hypertrophy (muscle gain)
 
Weight management
 
Slimming
 
Sport specific
 
Weight loss
 
Other
 
 
 
 
What is your mental goal?
 
Happier
 
More satisfied
 
Positive
 
Self-confidence/Self worth
 
Respect
 
Other
 
 
 
 
What does your body say about your mind and your mind about your body?
   
 
 
 
How do I feel about my body?
 
Satisfied
 
Somewhat satisfied
 
Unsatisfied
 
Very satisfied
 
 
 
Hello:
You are invited to participate in our lifestyle questionnaire of Ultima Potentia. In this survey, all clients will be asked to complete a survey that asks questions about their lifestyle. It will take approximately 10 minutes to complete the questionnaire.

Your participation in this study is mandatory. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point, and speak to your consultant. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Mr. Shaun Nortje at [email protected].

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
Thank you for your participation