Metabolic & Hormonal Health Questionnaire
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Height
Weight
Age
Lifestyle Assessment
How would you rate your sleep quality?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many hours of sleep do you typically get per night?
Less than 5
5-6
7-8
More than 8
What is your stress level?
No stress
1
2
3
4
5
6
7
8
9
Terrible Stress
10
1 is No stress, 10 is Terrible Stress
How would you rate your energy levels throughout the day?
Exhausted
1
2
3
4
Energetic
5
1 is Exhausted, 5 is Energetic
How many meals/snacks do you eat per day?
Do you skip breakfast?
Yes
No
Sometimes
Most of the time
Do you track calories?
Yes, Calories & Macros
Yes, Calories Only
No, But I have previously
No, Never
How active is your lifestyle
Sedentary
Light Activity (walking)
Moderately Active (Exercise 3-4x per week)
Very Active (Intense training or physical job)
If currently training, what type of training do you do?
Metabolic Health Indicators
Do you experience any of the following
Frequent Fatigue or Low Energy
Difficulty Losing Weight or Maintaining a Healthy Weight
Cravings for Sugar or Carbs
Irregular Appetite (eg, skipping meals, overeating)
Digestive Issues (e.g, bloating, constipation, diarrhoea)
Do you feel your body holds onto weight, especially around the mid section?
Yes
No
Do you experience frequent headaches or brain fog?
Yes
No
Hormonal Health Indicators
Do you experience irregular menstrual cycles or severe PMS Symptoms?
Yes
No
N/A
Have you noticed changes in your mood, such as increased anxiety, irritability or depression?
Yes
No
Do you experience difficulties falling asleep or staying asleep?
Yes
No
Do you experience hot flashes, night sweats or other signs of hormonal imbalances?
Yes
No
For men, have you noticed reduced muscle mass, energy or libido?
Yes
No
N/A
Additional Information
What health or fitness goals are you hoping to achieve?
What's is your primary health goal? (Weight loss, Muscle Gain, Energy Improvement, Hormonal Balance etc.
Have you ever worked with a Nutritionist before?
Yes
No
Which Coach would you like to work with?
*
Beck
Chris
Either
What is motivating you to work with PKLD right now? What's your primary objective?
*
Is there anything else you'd like us to know about your current health or lifestyle?
Submit
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