First & Last Name *
Phone Number *
Email Address *
Current Weight *
Goal Weight
Current Body Fat % (if known)
Goal Body Fat % (if known)
Height (in feet & inches) *
Age *
Please select the description that best describes your activity level. *
On a scale of 1 - 10 how aggressive would you like to be with your nutrition plan?
Not very aggressive - slight calorie change
Extremely aggressive - large calorie change
Clear selection
Will you be doing some kind of resistance training on a regular basis?
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Would you prefer following a high protein diet or a moderate protein diet?
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Would you say you prefer to eat more carbs or fats on a typical day?
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Which body type would you say best describes you.
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Do you have any existing health conditions? ​​Are you taking any medications?
What is your goal?
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Please describe a typical 24 hour day. Include your work schedule and any other responsibilities, activities, and stress levels. Be sure to include when and what you eat within this sketch.
What diets have you tried in the past? Which did you like and which did you dislike?
Do you currently experience excessive stress on a regular basis?
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How do you currently practice self care? Things like meditation, relaxation, exercise, journaling, traveling, seeing a counselor, etc.
On average how many hours a night do you sleep?
How is your sleep quality on most nights?
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Tell me about your exercise routine. Including what type of exercise, how many hours a week you exercise, and the intensity level.
Please tell me what type of exercise you'd like included on your personalized health plan.
How confident are you that you'll be able to follow a personalized health plan long term?
Not Confident
Extremely Confident
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Is there anything else you'd like me to know?
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