Full Name
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Email
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Height
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Current Weight
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Do you have any medical conditions you wish to disclose? (I.E. diabetes, hypothyroid, high cholesterol, etc)
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I agree to receive emails from Fit Habit Coaching.
What is your primary fitness/weight loss goal?
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Weight Loss (more than 20 pounds to lose)
Performance (optimize my performance for a sport)
Build Muscle (build lean tissue to improve body composition and strength)
Health/Longevity (I want to live my life the best way possible. I want to feel my best!)
Aesthetics (I just want to look good naked! I have an event coming up I want to prepare for)
Other
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Other
Have you done any fad diets/what have you tried in the past?
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How many calories on average are you eating per day?
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Rate your protein intake:
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1: Barely eating protein
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10: Eating close to, at or above 1g of protein per pound of body weight (or protein with 2-3 meals/day)
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Rate your food quality:
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1: Not paying any attention to what I am eating/poor food quality
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10: Eating green veggies at a minimum of 2 meals per day/80% whole foods
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Do you drink large amounts of caffeine to get through the day?
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Rate your daily energy levels:
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1: Low energy
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10: Very high energy
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Rate your daily stress levels:
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1: No/low stress
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10: Very high levels of stress
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Are you able to cope and manage your day to day stress?
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If you answered yes to the previous question, how do you cope with day to day stress (ex. walks alone, meditation, reading, watching TV)
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On average, how many hours of sleep do you get each night?
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Rate your sleep quality:
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1: wake up several times a night/wake up tired
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10: sleep like a rock/very high energy upon waking
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Do you have a sleep routine (I.e. go to bed and wake up at generally the same time each day)
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How active are you?
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Very sedentary (no exercise routine/desk job)
Sedentary (no exercise routine/minimally active during the day)
Moderately active (exercise 1-2 days per week/about 5k steps a day)
Active (consistent exercise 2-3 days per week/active throughout the day)
Highly active (physically demanding job/consistent exercise or consistent exercise 4-5 days per week and 8-10k steps/day)
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This assessment is not about coaching but are you interested in hearing more about 1 on 1 coaching?
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YES
NO
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