Congratulations for taking this step to healthy habits!
This questionnaire allows better customization to your program, and precise meal planning to achieve your goals. However results are based on client discipline, and participation. Result will not be extremely fast, and goal dates are not guaranteed, we use goals for a measure. Genetics, body type, and lifestyle all play a part as well. We will NOT be using fad diets! Throughout your time with me you will learn healthy habits, and zero in on unhealthy habits. You will adopt a lifestyle fit for you that you can take with you forever.
Name
*
First Name
Last Name
Email
example@example.com
Have you ever spoken one-on-one with a nutrition coach? Choose the most appropriate answer.
More than 3 times
Once or twice
Never
Do you have any food allergies or intolerances? If yes, list below.
Do you take any supplements or vitamins? If yes, list below.
What do you eat and drink on a regular basis?
What are some of your favorite foods and beverages?
Do you have any concerns with your current eating habits? If yes, explain below.
Do you have any challenges with healthy eating? If yes, explain below.
Do you have any major health concerns or issues? List below
Other members of the house-hold that affect your eating habits?
Would you consider yourself an emotional eater?
Yes
No
Not sure
How often do you skip meals? Choose the appropriate answer.
*
Daily
Occasionally (a few times a week)
Rarely (a few times a month)
Never
Average meals eaten in a day
1
2-3
4-5
More than 5
*Include snacks!
Select ALL that apply.
I eat when I'm bored.
I eat when I'm unhappy, or had a bad day.
I starve myself as punishment when I eat bad.
I binge eat snacks and mea
What would you like to accomplish during your one-on-one nutrition session?
What would you like your meal plan to include? (Select all that apply)
Meals for 5 days
Meals for 7 days
Snacks
Breakfast
Lunch
Dinner
Are you an Herbalife client?
Yes
No
Whats your current activity level?
None Active
Somewhat Active ( Walking outside )
Moderately Active (Workout 1-3x a week)
Very Active (Workout 4-7x a week)
Current weight
Goal weight
Choose the best answer that describes you!
I would like to lose weight quickly!
Slow and steady wins the race!
I just want to be healthy!
I would like to gain weight fast!
How committed are you to sticking to your lifestyle plan?
I'm not sure
I'm somewhat committed.
I'm committed!
I'm very committed!
I would hope to achieve my goal by:
-
Month
-
Day
Year
Date
Are you willing to download, and use the Myfitnesspal food diary app so I can keep track of your progress?
Yes
No
The answers I've given are truthfully answered to best of my ability.
*
I agree
Submit
*Please allow 1-2 Weeks for a custom meal plan depending on your desired specifications!
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