Lifestyle Questionnaire Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of Consultant / Presenter(Required) First Last Consultant / Presenter Email Address(Required) How often do you cook in a week?(Required)Do you enjoy cooking? Why or why not?(Required)In your daily meal planning, please check the 3 most important. Write the most important in the space provided.(Required) Nutrition Speed Clean Up Flavor Cost Variety Presentation Quantity Which of these is the most important to you?(Required)Are you trying to eat healthier?(Required) Yes No Do you find it difficult to get your children to eat healthy?(Required) Yes No N/A Please circle if you have family history of any of the health challenges below.(Required) Heart Disease High Cholesterol IBS Alzheimer’s/Dementia Colitis Diabetes High Blood Pressure Cancer Obesity Acid Reflux Select AllDo you think your food impacts you and/or your family’s health?(Required) Yes No What can help you cook more?(Required)What dishes would you like to learn to cook?(Required)What is your biggest health investment so far?(Required)On a weekly basis, how much do you spend on FOOD? Groceries & restaurants?(Required) $100 $150 $200 $250 $300+ If you were impressed, would you recommend us to your family and friends?(Required) Yes No Based on today's presentation, what is the most critical change you must make to cook and eat healthier?(Required)What would be the biggest benefit when you start cooking with SALADMASTER?(Required)Please rate this Presentation (Scale of 1 to 10)(Required)Comments or Suggestions(Required)Which of the following programs or classes that we have would you like to participate in? PLEASE select as many as you want.(Required) Healthy Meal Prep Class Deep Sleep, Stress Less Class Alzheimer’s Prevention Class Virtual Cook-Along Class In-Person Cooking Class African-American Nutrition Class Diabetes Prevention & Reversal Class Food Addiction Class Cancer Prevention & Survival Class Immune Boosters, Busters Class Thank you for taking the time to see our HEY Home Cooking presentation with SALADMASTER!May we publish your photo and review in our social media accounts and marketing materials? Please initial.(Required) Yes No For a chance to win a SALADMASTER item, please write a review of your experience in this presentation. Your name will be included in our month-end drawing.Do you know someone who would be great at doing this presentation?(Required) Yes No HEY Home Cookinghttps://heyhomecooking.com/ Δ
