4Leaf Data Collection Form

Special Group Request for Data

Studying the association between diet-style, prescription drugs and BMI

by J. Morris Hicks

Thank you in advance for participating in this study by sharing a little information about yourself and your dietary habits. Note that you must be at least 18 years old to participate.

Assessing your diet-style. We use our online 4Leaf Survey to do that. It is a simple, 2-minute, multiple choice questionnaire at 4leafsurvey.com. After taking the survey, you will be given an opportunity to receive a complimentary custom report about your current diet-style.

Please email your answers to these seven questions to [email protected]

1. Group I.D. (provided by your sponsor)

2. Age in years: (must be at least 18)

3. Sex:

4. Your numerical 4Leaf Survey score:

(This will range from -44 to +44)

5. How long, in years, have you eaten like this?

6. Using BMI Calculator, what is your BMI?

7. How many prescription drugs do you take?

( Note: Do not include contraceptives or drugs for mental-related conditions like depression or ADD.)

If you are on our mailing list, we will send you the results of this study. Click here to join mailing list.

Thank you for participating! The data you share will play a big role in helping large, self-insured corporations choose innovative corporate wellness strategies that will promote global health for humans and for the ecosystem that supports us all.

If you have any questions, please email me at [email protected]. We can also arrange to talk on the phone if you prefer.

Be well,

J. Morris (Jim) Hicks

CEO, 4Leaf Global, LLC

The 4Leaf registered trademark, the

4Leaf Survey, the ARCH system and all other 4Leaf materials are intellectual property of 4Leaf Global, LLC.

Check out our 4Leaf Survey as used at eCornell

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Want to get started nurturing your own health and the health of our planet? Take our survey at 4leafsurvey.com

Click here to learn more about this free online dietary assessment tool.

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J. Morris (Jim) Hicks 4leafprogram.com 917-399-9700

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