Nutrition Club health survey
This will only take 2–3 minutes 💚
Full Name
Phone
*
Date of birth
Email
*
Do you eat breakfast everyday?
Yes, most days
Sometimes
Rarely
Never
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Do you exercise on a regular basis?
Yes
No
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Do any of the below statements apply to you?
I am an emotional eater
I Struggle with a lack of energy
I often feel bloated and uncomfortable
I binge eat
I struggle with motivation
I struggle to lose weight
Do you have any specific health/wellness goals for? (eg:- Increase energy, better sports endurance, lose weight, gain muscle mass)
What are your biggest challenges when it comes to achieving your health/wellness goals?
Time
Motivation
Energy
Consistency
Knowing what to do
Other
Please specify if other
If we could help you improve things like energy, motivation, weight, confidence and your relationship with food — would you be open to support?
Yes i'd love support
Possibly I'd like more information
Not right now
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