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Required fields indicated with an asterisk (*)

How did you hear about the Yakult ‘Self Defence’ programme?
On-pack sticker
Recommended by a friend/family
Yakult website
Online search
Mailing
Other

Title
Mr            Mrs            Miss            Dr
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   * First Name
   * Surname
   * Gender
Male            Female
   * Date Of Birth (DD/MM/YYYY)
   *
Email Address
We need this so we can send you updates throughout the plan.
   * Confirm email address
   *
Password
This is so we know it’s really you. Keep it simple.
   * Confirm Password
   * Where do you live?
UK            Ireland            Other
If you give us your address, we’ll be able to surprise you in the
post. And we definitely won’t pass your address to anyone else.
Address 1
Address 2
Town
County
Post Code
Country
   *
   *
On average, how many glasses of water have you drunk per day in the last week?
1            2 to 4            5 to 7            8+

On average, how many portions of wholegrains/fibre
have you had per day in the last week?
E.g. wholegrain cereal, wholegrain bread etc.
0            1 to 2             3 to 4            5+ 		logo
   * On average, how many exercise sessions have you done in the
last week? E.g. 20 min walk, exercise class, gym session,
stretching etc.
0            1 to 3            4 to 5            6+
   * How many portions of fruit and vegetables have you had per day in the last week?
0            1 to 2            3 to 4            5+
   * How many units of alcohol have you had per day in the last week?
0            1 to 5            6 to 10            11+
   * On average, how many sugary snacks have you had per day in the last week?
Less than 1            2 to 3            4 to 6            7+
   * How has your gut health been in the last week on a scale from
1 to 4 (1=terrible, 4=perfect)? E.g. have you suffered from
bloating, conspiration, flatulence, diarrhoea.
1            2            3            4
   * How energetic have you felt in the last week on a scale from
1 to 4 (1=not at all, 4=very)?
1            2            3            4
   * How stressed have you felt in the last week on a scale from
1 to 4 (1=not at all, 4=very)?
1            2            3            4
   *
When are you next planning on going on holiday?
In two weeks
In a month
In 2-3 months
In more than 3 months