Name * First Name Last Name Email * Age * Height * Weight * Goal Weight * Healthy Living Struggles * What do you struggle with most when it comes to living healthy. Check all that apply. Meal planning & prep Time to shop & cook food Working out regularly Knowing how to exercise for your specific goals Stress management Quality sleep Motivation & accountability What to eat/personal nutrition Eating Habits * How many meals (including snacks) do you eat in a day? 1 meal 2 meals 3 meals 4 meals 5+ meals Eating Out * How many meals do you eat out each week? 1-3 meals 3-4 meals 5-7 meals 8-10 meals Almost all meals Do you meal prep? * Yes No I would if I knew how Vegetable Intake * How many servings of vegetables do you have in a day? (1 serving = 1 cup) 1 serving, maybe 2 servings 3 servings 4 servings 5+ servings Feelings before/after eating * Check any and all feelings you experience before and/or after a meal regularly (at least 2-3 times/week) Overly hungry, famished Bloated +/or gassy Overly full (want to unbutton my pants full) Still hungry, unsatisfied (after a decent-sized meal) Headaches Tired, sluggish Forcing yourself to eat (aka: not hungry) Sick, nauseous Grocery Shopping * How often do you grocery shop each week? 1 time 2 times 3+ times Water Intake * On average, how much water do you drink in a day? 0-1 cups 2-4 cups 5-7 cups 8-10 cups 10+ cups Qualify Your Lifestyle What is your daily activity like Active (moving around most of the time) Moderately active (up and down throughout the day) Sedentary (desk-bound) Working Out * Where do you workout most? A gym At home Outside Cardio * In a week, how often do you do cardio? (for 30 minutes or more) 0 times 1-2 times 3-4 times 5-6 times 7+ times Strength Training * In a week, how often do you lift weights? 0 times 1 time 2 times 3-4 times 5+ times Sleeping Habits * On a scale of 1-10, how would you rate your quality of sleep? 1-3 (poor) 4-6 (only ok) 7-8 (pretty good) 9-10 (all good!) Thank you! You will receive a response to your assessment within 24-48 hours.
