General information
First Name
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Last Name
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Email
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Phone
I find making dietary adjustments...
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Nearly impossible to make a long term habit
Easy at first, but revert to old habits eventually
Totally easy for me to handle sustainably
Do you know exactly how many calories you consume?
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Yes
No
Do you log your food?
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Yes
No
What would you consider a healthy rate of weight loss?
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40lbs in a month
1-2lbs per week
20lbs in a month
Have you tried one or more "fad" diets?
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Yes
No
How do you navigate getting to your long term goals?
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I make mini goals
I focus solely on getting to that end goal
Do you know the function of each Macro Nutrient?
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Yes
No
Do you know how many grams of Protein you should be eating for your body?
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Yes
No
Do you know if you have any food sensitivities/intolerances?
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Yes
No
Do you have times where you feel your motivation is low?
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Yes
No
Have you noticed any patterns of setting intentions and not following through?
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Yes
No
What is your average daily step count?
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under 5,000 steps
5,000-10,000 steps
Over 10,000 steps
Do you eat fast food more than twice a week?
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Yes
No
How many hours of sleep do you typically get?
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under 5hrs
5-8hrs
8+ hrs
Do you often get overwhelmed with your tasks or commitments?
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Yes
No
How would reaching your goals improve your overall quality of life?
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On a scale of 1-5 (1 being low and 5 being high) how commited are you to reaching your goals?
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