Metabolism Assessment

First Name *

Last Name *

Email *

Phone *

Date of birth *

Height (in cm) *

Weight (in lb) *

How many (lbs) would you ideally like to lose? *

over 100

50-99

20-40

under 20

How long have you been eating in this calorie range? (if you don't know your range, select the "no idea" option) *

More than 1 year or no idea

6 months to 1 year

Less than 6 months

How much protein do you eat each day in grams? *

No idea

Under 100

100 - 120

More than 120

How many veggie and fruit servings do you have a day? (serving is 2 cups of veg or 1 piece of fruit) *

none

one

3 or more

How many litres of water do you drink each day? *

under 500 ml

1-1.5 litres

2-2.5 litres

3 or more litres

How many steps a day do you get on average (for estimates, 30 minutes intentional walking is ~ 4000 steps) *

Under 4000

5000 - 8000

7000 - 8000

More than 8000

How many times a week do you currently strength train? *

None

1-2 times

3-4 times

More than 4

How many hours of structured cardio (non-walking) do you do each week? *

3-4 hours

1-2 hours

None

How would you rate your stress levels? *

high stress

moderate stress

no stress

How would you rate your quality of sleep? *

poor sleep - wake up 2-3 times or can't go back to sleep

moderate sleep - wake up 1-2 times but can go back to sleep

restful sleep - rarely wake up

sleep like the dead

How many hours of sleep do you get each night? *

Under 5

6-7

8 or more

How would you rate your energy levels in the morning? *

Poor

Average

Energizer bunny

How would you rate your energy levels in the afternoon? *

Poor crash and burn

Average most days

Energizer bunny

What time do you eat breakfast each day? *

I don't or skip often

within 1.5 hours of waking up

within 3 hours of waking up

Are your meal times regular? *

Sometimes

Always

How many meals a day do your currently eat including snacks? *

less than 2 or snack all day and don't eat regularly

Are you typically hungry in the morning? *

not hungry

sometimes hungry

always look forward to breakfast

How many times a week do you eat out? *

4 or more

2-3 times

1-2 times

none

What % of your foods come from processed foods? (Processed = foods made mostly outside your kitchen for convenience; not meals made from whole ingredients) *

More than 40%

30-40%

less than 20%

How often do you get cravings? *

multiple times a day

once a day

once a week

rarely

How many times have you lost 15 lbs or more and gained it back (or more)? *

5 or more

3-4 times

1-2 times

never

How many of these do you experience more than 2X a week? Bloating, constipation, Heartburn, Bad Gas, Diarrhea, burping, food sensitivities? *

3 or more

none

Choose a range for how many of the below apply:

Peri-menopause

Menopause

Hypo Thyroid

Diabetic

High A1C

High Blood Pressure

Hashimotos

PCOS

High Cholesterol

Any other auto immune

Choose Below *

3 or more

None of the above

How many of these symptoms do you have or have you experienced in the last 6

months:

Tired but wired feeling

Struggle to calm down before bedtime

Difficulty falling asleep or disrupted sleep

Sleep disturbance particularly between 1-4am

Increased anxiety or nervousness

Drastic mood swings, including "weepiness

Quick to feel anger/ rage

Decreased motivation in most things

Memory lapses, struggle to stay focused

Sugar cravings

Rapid Weight gain in hips, butt or stomach (gained 10 + lbs)

Difficulty in coping, decreased stress tolerance

Muscle or joint pain, especially around knees

Bloating, puffiness or water retention

Brain fog/ poor memory

Gall bladder problems

Night sweats/ hot flashes

A leaky or overactive bladder

Vaginal dryness, irritation or loss of feeling/ painful sex

Low libido

Excess hair on face, chest or arms

Acne

Greasy hair and/or skin

Hair Loss

Irregular Periods Or Heavy Periods

Choose below *

3 or more

None of the above