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Healthy Diet Lifestyle Survey Form
Please fill out the form carefully
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Full Name:
*
First Name
*
Last Name
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*
Email id:
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Please enter valid email address
*
Mobile No:
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Invalid phone number.
The value must be less than or equal to 20
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Gender:
Male
Female
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What will you have for your daily breakfast:
Rice
Noodles
Bread
Coffee
Skip Breakfast
Others
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Please specify :
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*
How much cost is your daily breakfast:
$ 30
$ 30-50
$ 50
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Is your breakfast provides all the nutrients that your body needs in a day, For example mineral, vitamin and protein:
Yes
No
I'm not sure
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If there is a healthy breakfast that can help you to improve improve body immunity and a bonus that help you to lose weight or gain weight. Are you interested to know more about this:
Yes
No
Can consider
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*
You wish to know more on:
Improve energy, body conditions & immunity
Lose fats
Gain muscle
No need
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Comments:
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Submit