Form
New Nourished AF Wellness Questionnaire
By answering the following questions, I will have a better understanding of your wellness goals in order to help you choose the best plan to fit your needs.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GENDER
Please Select
FEMALE
MALE
Why are you interested in joining my online wellness group?
My Top 3 FITNESS goals:
Build Strength
Improve Endurance
Improve Flexibility/Stability/Mobility
Gain Lean Muscle/Lose Fat
Sports-specific Training
Total Body Toning
Core Strength
OTHER:
My Top 3 NUTRITION goals:
Eating for weight loss
Guidance on special diets (gluten-free, vegan, etc.)
Portion Control
Meal Planning
Recipe Ideas
Balancing macros/micros
Nutrition for exercise performance
Control health risk factors (heart disease, high BP, cholesterol, diabetes, etc.)
Tips for eating out/on-the-g-
OTHER:
Are you open to participating in an online wellness group?
YES
NO
UNDECIDED
Have you ever used supplements to support your health & fitness goals?
YES
NO
UNSURE
What types of workouts do you enjoy most? (check all that apply)
HIIT
Pilates/Yoga
Barre
Strength & Conditioning
Dance
Cardio
Stretching/flexibility
Spinning
Abs/core
Workouts 30 minutes or less
Workouts 45 minutes or less
Workouts more than 45 minutes
Low Impact
Low/Mod Intensity
What would best help you stay consistent?
Do you have any of these issues?:
Trouble sleeping
Lack of energy
Brain fog
Skin irritations
Bloating
Constipation/Loose stools
Stomach discomfort after eating
Stress
At what age did you feel your very best?
How often do you take (uninterrupted) time for yourself?
OFTEN
OCCASIONALLY
RARELY
NEVER
If you knew you could reach your goals, how much would you be willing to invest in your heath and wellbeing?
$200-$300/month
$100-$200/month
Less than $100/month
I only want free programs
As your coach, how can I best help you achieve your goals?
Do you have difficulty:
Losing weight
Gaining weight
Maintaining weight
No difficulties
Do you have any food sensitivites?
What are your favorite flavors?
Chocolate
Vanilla
Strawberry
Cafe Latte
Cookies & Cream
What is your preferred method of communication?
Please Select
EMAIL
TEXT
FB MESSENGER
INSTAGRAM MESSAGE
PHONE CALL
Submit
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