Sugar Questionnaire

Sugar Questionnaire

To help me help you, please answer these questions accurately and honestly.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Age *
Email*
example@example.com

On a scale of 1 to 10 how would you score your desire to eat sugary foods?*

	1	2	3	4	5	6	7	8	9	10

1 is No Desire, 10 is Full of Desire

Briefly describe your main reason for wanting to give up/reduce processed sugar?
Add as much information as you feel relevant.
What sugary products do you want to give up? Please be specific with your answer. What brands etc? Please put a number next to each item to indicate how many you eat each day.
Add as much information as you feel relevant.
Have you tried any weight loss or lifestyle diet programs in the past? If so, please add them below.
Add as much information as you feel relevant.
Are you presently suffering from any sugar related illnesses? and if so, does this include prescribed medication.
Add as much information as you feel relevant.
Have you ever worked with a hypnotherapist before?

YESNO
If you haven't read the articles or watched the videos I recommended on my website yet - go ahead and watch the video below to get a science based critique on the dangers of excess sugar and how we take it for granted.
Should be Empty: