Health & Nutrition
Email address *
Coach Bernard - Health & Nutrition Questionnaire
Who is your coach?
Your Coach *
Title *
Title
First Name *
Surname *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Weight in lb *
Desired Weight in lb *
Waist size in cm *
Desired Waist size in cm *
Body type *
Where is your energy level, on a scale of 1 to 10? *
Desire to
Put on weight
Lose body fat
Lose mid section fat
Drop waist size
Drop dress size
Get fit
Need more energy
YES
Desire to
Build Muscle
4 PACK
6 PACK
8 PACK
YES
Why? *
I’ve tried .....
Herbalive
Amway
Weight watchers
Slimming world
Atkins diet
Miami diet
Row 1
I’m interested in ..... *
Required
I’ve tried .....
Atkins diet
Cambridge diet
South Beach Diet
Vegan Diet
High fat diet
Ketogenic Diet
Row 1
I’ve tried .....
Paleo Diet
Slim Fast diet
LighterLife diet
Sugar-free diet
Row 1
How long did you try each one, and what were the results?
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