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How to go about getting started? Yes/No
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What does it take to be a candidate? Yes/No
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How long does it take to be accepted as a candidate? Yes/No
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Are you a smoker? Yes/No
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Are you a drinker? Yes/No
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How much caffeine do you consume in a day? _cups/_cans/_mg.
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Do you take a multivitamin daily? Yes/No
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Other vitamins or supplements? Name them___________
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Are you? Single/Married/Divorced/Separated
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Age Group? Teen/20's/30's/40's/50's/60's/older
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How much do you need to lose to be healthy? Les then 50lb's/51-75lbs/76-100lbs/101-150lbs/151-200lbs/more
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Do you exercise? Never/Rarely/weekly/daily/sometimes?
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What are your favorite types of Food groups? Meats/Vegetables/Fruits/Nuts and Grains/Dairy/Junk Food/Variety
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List 3-6 favorite Foods/Drinks consumed daily?
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Do you think there is a need for this type of group in this in Central Iowa? Yes/No
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Would you sign up for this group? Yes/No
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Would you like information on complications w/this procedure and post operative? Yes/No
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What location in Central Iowa would be best for you to travel to?
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How many miles would you be willing to travel to join this group? 10miles or less/up to 25 miles/up to 50 miles/or more?
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Would you be willing to share your experiences with others? Yes/No
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Would you be willing to share recipes/samples w/others? Yes/No
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Would you like your group to be small-15 people or less, medium 30people or less or large-more than 30 people?
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Would you prefer to be in the same age group type? Yes/No/Doesn't matter
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Would you prefer to be in Men's only/Women's only/Teen's only/Doesn't matter?
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Would you prefer to be in a single's group/married group/divorced group/separated group/doesn't matter?
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Are you willing to pay to go to such a group to help cover costs of materials/start-up costs/speakers/food samples? Yes/No
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How long would you like such a group to meet? 2hr's or less/3-4hr's/all day including lunch & breaks/other?
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Do you need assistance w/daycare/familycare or transportation to attend such a group? Yes/No
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Optional:If interested please list your name___________
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If you would like to be contacted about such, list a phone number you can be reached at__________________
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