Fitness questionnaire

Questionnaire

Answer honestly so I can see where you’re at and how a CounterStep plan could help you Break The Cycle.
Name

First NameLast Name
City, State, Country
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Age
Height
Weight
Body fat % (if known)
Birth gender
4. What’s your main focus right now?

Other
5. How many days per week do you exercise? (0–7)
6. What types of exercise do you do most weeks? (check all that apply)

Other
7. How would you describe your current eating habits?

Other
8. What’s the biggest thing holding you back right now?

Other
12. Any medical issues?
9. Any dietary restrictions or medical food limitations?(Allergies, medical conditions, religious restrictions, etc)
10. Protein foods you like and will eat
List a few. Example: eggs, chicken, Greek yogurt, steak, cottage cheese, etc.
11. Carb sources you enjoy and could eat regularly
Example: rice, potatoes, oats, fruit, tortillas, etc.
12. Any foods you absolutely do not like or refuse to eat?
13. If accepted, how committed are you to following a CounterStep plan to Break The Cycle?
Pick a number from 1–10, where 1 = not committed and 10 = all in.
14. If you’ve seen the CounterStep menu, do you already have a plan you’re most interested in?
If yes, which plan caught your eye?
Should be Empty:

Questionnaire