Wellness Profile
Name
*
First Name
Last Name
I ask this question to be able to offer the right wellness recommendations for you.
*
Male
Female
DOB:
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What are your wellness goals?
*
Current weight?
blanks
*
. Current Height?
blank
*
.
Target weight?
blanks
*
.
How much do you want to lose/gain?
*
What other wellness programs/products have you tried in the past to achieve your nutrition goals?
*
What results have you experienced with these programs/products?
*
What did you eat yesterday? (Don't leave anything out)
*
How many times do you eat each day?
*
1 meal
2 meals
3 meals
3 meals + snacks
Just snacks
1-3 snacks
What do you snack on?
*
How many glasses of water do you drink each day? (Each glass is equal to 8 ounces of water.)
*
0 glasses
1-2 glasses
3-5 glasses
5+ glasses
What is your activity level? (How frequently do you exercise 30 minutes or more?)
*
Inactive/sedentary: 0-1 times per week
Moderately Active: 1- 2 days per week
Active: 3 days per week
Very Active: 4 or more days per week
What else do you drink?
*
Tea
Soda
Juice
Alcohol
Coffee
Energy Drinks
Other
How many times a week do you eat out?
*
Where?
*
Average cost per meal $?
*
What is your energy level on a scale of 1 to 10? 10 being the most
Please Select
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2
3
4
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9
10
Submit
Should be Empty: