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Health survey
This questionnaire will allow me to get to know you better and identify your needs. Be honest and don't be afraid to write down details. Your answers will remain between you and me. So we can together establish your goal and establish the steps to get there.
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Email address
Your answer
Instagram Username - if you prefer instagram vs email to be contacted.
Your answer
Name & Age
Your answer
Do you have a active job?
Active
Moderate
Desk job
Clear selection
Are you an active person
No
Gym
Yoga, dance, zumba
walk, hike
Other:
Clear selection
What is your body type
Ectomorph - long and lean, with little body fat, hard time gaining weight and muscle mass
Endomorph - have lots of body fat, lots of muscle, and gain weight easily,
Mesomorph - Naturally muscular body, no difficulty in loosing or gaining weight
Clear selection
What are your goals
Gain healthy weight & or muscle mass
Loose weight
Develop a better digestive system
Gain more energy
Sleep better
Find a good skin care routine
Other:
Clear selection
Digestion Problems ?
No I'm good !
Gas / Bloating
irregularity / constipation
Diarrhea
Other:
Clear selection
Do you take any medication ? If so for what.
Your answer
Relevant Disease, allergies or intolerances?
Your answer
How is your average energy level ?
Low
1
2
3
4
5
6
7
8
High
Clear selection
How is your sleep
Good !
Could be better
Insomnia
Clear selection
How many times a day do you eat ?
Less than 3
3 meals only - breaky, lunch and dinner
between 3 and 5 - breaky, snack, lunch, snack , dinner
3 and more
Clear selection
Do you eat out ? If so how many times a week or a month ?
Your answer
Coffee consummations or Tea
Coffee
Tea
Both
More then 2 cups of coffee a day
Other:
Clear selection
Alcohol consumption
Yes once in a while
Frequently
no
Clear selection
Do you smoke or consume any other drugs
Smoke
Neither
Other:
Clear selection
Skin problems
No !
Acne
Eczema
Cellulite
stretch marks
wrinkles / fine lines
Other:
Clear selection
Other thoughts or comments
Your answer
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