Nutrition Questionaire

What specific physical goals do you currently desire? (I.e. body weight, body fat, muscle gain, health marker improvements, confidence)

What barriers have you encountered before or do you think/feel will affect your success?

Rate your overall confidence (1-10)

	1	2	3	4	5	6	7	8	9	10

1 is No self confidence, 10 is I truly love and accept myself

Rate your confidence in your ability to change (1-10)

	1	2	3	4	5	6	7	8	9	10

1 is I don’t think I can, 10 is I GOT THIS!

What healthy behavior(s) are considering?

How long do you think your goal will take to achieve?

1-6 months6-12 months13- 24 monthsMore than 2 years

Answer the following questions as to how you feel:

	Strongly Agree (Daily)	Agree (Sometimes)	Neutral	Disagree (Rarely)	Strongly Disagree (Never)
I know what to eat and when to eat
I track my macros
I am happy with how I look
I feel healthy
I have sustainable energy throughout the day
I like the foods I eat daily
I go out to eat

Upload Pictures of your body here (front/side arms up/back/side):

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blanksWaist Inches (around belly button)blankCircumference around glutes Inches