Name:
Email:
Phone Number:
Address:
Gender
Female
Male
Prefer not to say
Other
What is your height?
What is your age?
What is your current weight?
What is your top nutrition goal(s)?
Weight Loss
Weight Gain
Gain Muscle
Maintain Weight
More Energy
Balanced Nutrition
If you said weight loss or weight gain, what is your goal weight?
What have you tried to reach your goals that did not work for you?
Do you eat three meals a day?
Yes
No
Other
If no, which meals do you skip?
Breakfast
Lunch
Dinner
Do you snack throughout the day?
Yes
No
If yes, what do you snack on?
How many times a week do you eat out?
I never eat out
Maybe once a month
1-2 times/week
2-4 times/week
5+
Other
About how much water do you drink per day? (To put into perspective a gallon is 128 ounces, most water bottles are 24-32 ounces) *
20-50 ounces
50-80 ounces
80+ ounces
Other:
What else do you drink in the day besides water? *
Juice
Milk
Tea
Coffee
Energy Drinks
Pop/soda
Alcohol (any)
Other:
In regards to tiredness, what time/s are you the most tired and have the least amount of energy?
When do you find yourself the most hungry?
Do you have any questions, concerns, or comments regarding this wellness profile?
Should be Empty: