Fix My Diet Assessment

1

Let's start with your full name.* This field is required.

First Name

Last Name

2

What's your email?* This field is required.

example@example.com

3

What's your phone number?* This field is required.

Please enter a valid phone number.

4

What's your age?* This field is required.

5

What's your biological sex?* This field is required.

MaleFemale

6

What's your height?* This field is required.

inches

7

What is your current weight in pounds?* This field is required.

pounds

8

What is your goal weight in pounds/dress size?* This field is required.

9

How many hours do you sleep every night?* This field is required.

less than 5 hours

5 to 6 hours

6 to 7 hours

7 to 8 hours

more than 8 hours

10

How much time do you spend sitting still every day?* This field is required.

1 to 3 hours

3 to 6 hours

6 to 9 hours

more than 9 hours

11

How do you feel when you're stressed on a normal day?* This field is required.1 = very stress | 5 = little stress

12

Does anyone in your immediate family have chronic health problems, like diabetes or high cholesterol?* This field is required.

YESNO

13

How many days each week do you exercise?* This field is required.

1 day or less

2 to 3 days

4 to 5 days

6 days or more

14

How long do you usually exercise for each time?* This field is required.

less than 30 minutes

30 to 45 minutes

45 to 60 minutess

more than 60 minutes

15

How often do you do things that involve physical activity, like walking, hiking or playing sports, outside of formal exercise times?* This field is required.

daily

weekly

monthly

never

16

What types of exercise do you like the most?* This field is required.

17

How many meals do you eat every day?* This field is required.

1 or less

2 to 3

4 to 5

6 or more

18

How many snacks do you eat every day?* This field is required.

1 or less

2 to 3

4 to 5

6 or more

19

How often do you eat food that has protein in it?* This field is required.

never

some meals

most meals

every meal

20

How often do you eat fruits or vegetables?* This field is required.

never

some meals

most meals

every meal

21

How much water do you drink every day?* This field is required.

less than 1 bottle

2 to 3 bottles

3 to 4 bottles

more than 4 bottles

22

Do you drink caffeine or other things that make you more alert?* This field is required.

YESNO

23

Do you ever drink alcohol?(skip if you're under 21 years old)

YESNO

24

How hungry do you usually feel after meals?* This field is required.1 = never full | 5 = always feel bloated

25

Have you ever felt like you couldn't stop eating a lot of food at one time, or felt like eating because of your emotions?* This field is required.

YESNO

26

Do you use an app to keep track of what you eat?* This field is required.

YESNO

27

What performance or wellness goals would you like to achieve in the next 6-12 months?* This field is required.(losing weight is not specific enough...provide detail)

28

What have you tried in the past and why hasn't it worked for you? What's stopping you from hitting your goal?* This field is required.The more specific you can be the more clarity we can provide during our consult together.

29

What will happen if you do not act now on these goals? Where will you be a year from now if you don't take action?* This field is required.

30

How badly do you want to make the changes necessary to improve? As in, is this a priority right now or I'll give to it when I can make time sometime in the future?

31

Occupation* This field is required.(write student if you're in MS or HS)

32

This is a completely complimentary survey for all G4 Wellness community members. After the results are submitted, how would you prefer to receive the results to help you?* This field is required.

Complimentary guide/video with the main findings- I'm NOT interested in achieving my goals with 1-1 coaching at this time.

Complimentary video with the main findings- I am interested in learning more about 1-1 coaching because I'm tried of trying to figure this out on my own!

Complimentary 15 min call/in person consult to review the results. I am serious about achieving my goals and I am interested in learning more about 1-1 support with you! *serious inquiries only

33

If you were able to find a way to reach your wellness goals through our G4 Wellness coaching program, would you be willing (and able) to invest in getting the help necessary to get there?* This field is required.

Yes- I have the cash flow to invest in myself.

Yes- I would be resourceful and willing to finance to invest in myself.

No- my cash flow is month to month and I have no access to credit.

34

How long have you known or been part of the Vale community?* This field is required.Example: 1 month, 1 year, I'm a lifer :)