LXHarmony Survey

1

Name

First Name

Last Name

2

Phone Number

Please enter a valid phone number.

3

Email

example@example.com

4

Age

5

Occupation

What do you do for a job

6

Do you have any medical condition? (e.g., diabetes, hypertension, heart disease)

Yes/no: If yes, please specify

7

Are you currently taking any medications or supplements?

Yes/no: If yes, please list them

8

Do you have any food allergies or intolerances?

Yes/no: If yes, please Specify

9

Have you ever been diagnosed with any eating disorders?

Yes/no: If yes, please Specify

10

How Many Meals do you typically eat per day?

1

2

3

4+

12

Do you follow any specific diet? (e.g., Vegetarian, Keto, Vegan, Mediterranean)

Yes/No,: If yes, please specify

13

How often do you eat out or order takeout?

Never

Rarely

Occasionally

Frequently

14

How much water do you drink daily?

Less than 1 Liter

2-3 liters

1-2 liters

3+ liters

15

Do you consume caffeinated beverages? (e.g, coffee, tea, energy drinks)

Yes/No: If yes, How many cups per day?

16

How often do you exercise per week?

Never

1-2 times

3-4 times

5+ times

17

What tyes of exercise do you usually do? (e.g., weightlifting, cardio, yoga)

18

How intense is your exercise routine?

Light

Moderate

Intense

19

Do you have any injuries or physical limitations?

Yes/No: If yes, please specify

20

What are your primary nutrition goals? (e.g., weight loss, muscle gain, improved energy)

21

Do you have specific macronutrient preferences or requirements? (e.g., high protein, low carb)

22

How Committed are you to following a nutrition plan?

Not Committed

Somewhat Committed

Fully Committed

23

Do you have any preferred foods or foods you dislike?

Yes/No: If yes, please specify

24

What’s your ideal timeline for achieving your goals?

In one month

In 2 months

In 3 months

In 4+ months

25

How important is it for you to have variety in your meals?

Not important

Somewhat important

Very important

26

How many hours of sleep do you get per night on average?

Less than 5

5-6

7-8

9+

27

Do you smoke or consume alcohol?

Yes/No: If yes, how often?

28

How would you rate your stress level?

Low

Moderate

High

29

Do you travel frequently?

Yes/No: If yes, how does it affect your eating habits?

30

Have you tried any diets before that have failed you?

Yes/No: If yes, specify the diet

31

Do you have any routines or activities that help you find peace or relieve stress? (e.g., meditation, spiritual walks, yoga, journaling, etc.)

Yes/No: If yes, Please describe them

32

How much do you currently weigh?

33

What is your height?