Questionnaire
Answer honestly so I can see where you’re at and how a CounterStep plan could help you Break The Cycle.
Name
First Name
Last Name
City, State, Country
Email
example@example.com
Phone Number
Age
Height
Weight
Body fat % (if known)
Birth gender
4. What’s your main focus right now?
*
Lose body fat
Build muscle
Recomp (lose fat and build/keep muscle)
Improve health/energy
I just know I need a change
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)
*
Weight training
Cardio treadmill, bike, running, etc
Sports / recreational activities
Walking / steps
My job is very physical
Other
7. How would you describe your current eating habits?
*
No real structure, I just eat
Weekdays are decent, weekends fall apart
I try to be mindful, but nothing consistent
I track or plan most days
Other
8. What’s the biggest thing holding you back right now?
*
Time / schedule
Food / meal prep
Motivation / consistency
Confusion (too much info, don’t know what to do)
Injuries / joint issues
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?
*
I haven’t seen the menu yet
Yes, I have a plan in mind
I’ve seen it but I’m not sure yet
If yes, which plan caught your eye?
Submit
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