Nutritional Coaching Questionnaire
Email address *
What is your name? *
Your answer
What is your phone number? *
Your answer
How old are you? *
Your answer
What is your current weight? *
Your answer
What is your ideal weight? *
Your answer
Where do you live? What time zone are you in? *
Your answer
1.Where are you in regards to your health right now ? *
Your answer
2. Where do you want to be in regards to your health? *
Your answer
3.Why do you want to reach your health goals? *
Your answer
4. What is in the way? *
Your answer
5. What is the problem? *
Your answer
6. What is it costing you to live with this problem? *
Your answer
7. How soon do you want to fix this problem? *
Your answer
8. What type of foods do you eat on a regular basis? *
Your answer
9. Have you dieted before? Did any of them work? *
Your answer
10. What types of drinks do you drink regularly? *
Your answer
11. Do you snack regularly? What type of snacks do you eat? *
Your answer
12. How many hours of sleep do you get at night? *
Your answer
13. On a scale of 1-10 , how much stress do you deal with on a daily basis? 1 (no stress) - 10 (a lot of stress) *
14. How often do you eat out a week? *
Your answer
The initial investment is $125.00 to go over blood work and the initial meal plan and an additional $75.00 for 3 meal plan revisions. Are you willing to make this investment? *
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