Personal Profile Survey

Select the answer that best describes you. If a question does not pertain to you, move on to the next question. You will need a tape measure to complete this profile.

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Q1 When it comes to feeling hungry	Rarely get hungry, can go for a long time without eating Often feel hungry, need to eat often It's only when I miss a meal
Q2 When I go 4 hours without eating	It doesn't bother me I begin to feel jumpy and irritable I feel normal hunger
Q3 When I eat before bed	It makes it harder to sleep well I sleep better It doesn't seem to matter
Q4 My general feeling about eating	I eat to live I Live to eat Have average eating habits
Q5 As for appetite	Not strong Strong Average
Q6 My digestion is	Poor, weak, slow Good, efficient Rather average
Q7 My feelings for fatty foods	Don't care for them Love them and can crave them Take it or leave it
Q8 I find a vegetarian meal	Satisfying Hungry soon after OK
Q9 Regarding salty foods	Food often tastes too salty Love and crave salt on food Feel I'm average
Q10 If I skip a meal	I'm fine Can't skip, must eat often OK but feel best with 3 meals
Q11 If I'm low on energy, I'm best with	Fruit, pastry, candy Meat or fatty foods Good with either
Q12 An orange juice only breakfast	Satisfies me, energizes me Can leave me feeling jittery, lightheaded, even nauseated No ill effects, rather neutral
Q13 If I fast on juice or water	I feel well I feel awful I feel OK
Q14 If I eat meat for breakfast (such as ham, bacon or sausage)	I get tired, lethargic and/or thirsty I feel energized and can easily go to lunch It's OK, but not in large portions
Q15 If I eat meat for lunch	I feel tired, sleepy, lose energy in the afternoon I feel good, full of energy, can go straight to dinner I feel OK
Q16 As for meal portions, I prefer	Small Large (or frequent) Average
Q17 As for desserts/sweets	I love sweets and need to have Don't really care for sweets (prefer salty snacks) Can take them or leave them
Q18 As for sour foods	Don't care for them Love them, could eat them every day Sometimes want
Q19 My feelings on potatoes	Not very fond of them Really like, can crave Can take them or leave them
Q20 If I eat red meat, I feel	A decrease in energy An increase in energy The same as before
Q21 As for snacking,	Rarely or never snack Want to/Do eat between meals
Q22 As for fatty foods	Don't care for them Love them, crave them Can live without them
Q23 If/when I eat fatty foods	Energy decreases Increases energy Stays about the same
Q24 Do I look my age?	Look older than others my age Look younger than others my age
Q25 My fingernails	Tend to be strong, thick, hard Tend to be weak, thin, soft
Q26 My facial coloring tends to be	Pale, chalky Ruddy, rosey
Q27 Goose bumps	Tend to form easily
Q28 My skin tends to crack	In any weather
Q29 I tend to get cold sores and/or fever blisters	Tend to get
Q30 I tend to get dandruff	Tend to get
Q31 My eyes tend toward	Dry eyes Moist and/or teary
Q32 I tend to get itchy eyes	Tend to get
Q33 My skin	Tends toward dry Tends toward oily/moist Seems average
Q34 My skin is itchy	Tends to be Average reactions
Q35 I tend to cough	Most every day
Q36 I tend to get chest pressure	Tend to get
Q37 My gums bleed	After brushing
Q38 The color of my gums tends toward	Light, pale Dark, pink, red
Q39 I tend to sneeze	Every day
Q40 I tend to wheeze	Rather often
Q41 My mouth tends	To be dry Full of saliva
Q42 My saliva tends to be	Thick Watery
Q43 If stung/bitten by insect	Weak reaction, goes away quickly Strong reaction, lasts a while
Q44 Cuts heal	Slowly Quickly In average time
Q45 As to the weather	I love it warm, hot I do well in cold, poor in hot It doesn't matter
Q46 As for my emotional level	I'm hard to read and not demonstrative Easily express my feelings
Q47 Socially I'm	Introverted, shy, non-talkative Extroverted, easily make conversation
Q48 I tend to be	Cool, aloof, hard to get to know Warm, open, make friends easily
Additional Required Information
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First Name
MI
Last Name
Address 1
Address 2
City
State
Zip
Telephone: Home
Telephone: Cell
Email Your email is not sold, shared or provided to any third party.
Date of Birth	(MM/DD/YYYY)
Sex
Height
Weight (If your weight is > 300 or < 120 Please email us at support@thenuweigh.com)
A tape measure will be needed for the following measurements. Be sure to measure in a straight line.
Waist (at natural waist line if clearly defined or 1 inch above the umbilical line, belly button)
Abdomen (2" below the umbilical line)
Hips (at the pubic line)
Wrist (THIS IS FOR MALES ONLY. Use dominant hand and measure right in front of the wrist bone)
Activity Level:	Sedentary: No exercise Light Activity: 2-3 Workouts/week including 30 minute aerobic activity (i.e. easy pace walking, easy pace stationary bike riding) Moderate Activity: 4-5 Workouts/week including 30 minutes aerobic activity PLUS Resistance training (bands, light weight lifting) Heavy Activity: 5+ Aerobic workouts per week for 30+ minutes PLUS heavy weight lifting
Goal:	Lose Weight Gain Weight Maintain Weight
Goal Increase Energy
Goal Healthier Lifestyle
Referral Code If you were referred to nuweigh, please enter the e-mail address of the person who referred you.
Create Password Your email and password is used to sign into your account.
Last 4 digits of your SSN This is a personal security check for you. (See Terms and Conditions, Below)
Mother's Maiden Name This is a personal security check for you. (See Terms and Conditions, Below)
nuweigh is not intended to diagnose, treat, nor prevent disease; though compliance with a comprehensive program, such as nuweigh, may lower one's risk for certain diseases and/or conditions associated with obesity and a sedentary lifestyle. Consult your doctor before beginning this or any weight loss and/or fitness program. Achieving desired results on the nuweigh program will vary from individual to individual and is based on the level of compliance of each participant. Due to the proprietary nature of each personalized program, Buyer acknowledges and accepts that in processing a customized program for that Buyer, he/she enters into a non-revocable agreement with nuweigh to fulfill the Buyer's request for service which will automatically result in a product with no resale value to any other individual; therefore fulfillment of Buyer's request results in a final sale The Buyer waives his/her rights to cancel said transaction at the moment the request to process it is given by the Buyer. In proceeding with this transaction, I understand that I am entering into a contract for service which is non-revocable as regards my request for nuweigh to produce a customized eating program for me as said program has no resale value to any other individual and whereas, absent of my request, nuweigh would not have processed the program. In pressing the SUBMIT button, I acknowledge I am 18 years of age, or older, and that I have read, understand, and accept the terms as herein described. To secure your personal file and assure that no-one, other than yourself, may access your personal information or transact an order with your credit card, please complete the following: Last 4-digits of your Social Security and your Mother's maiden name. This is considered your electronic signature. (nuweigh will never have need to ask for your complete social security number)
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Personal Profile Survey

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