Name
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First Name
Last Name
Facebook Name on profile
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Phone Number
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-
Area Code
Phone Number
Email
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example@example.com
Age
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Height
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Weight
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How many meals do you consume daily?
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1 time a day
2 times per day
3 times per day
4-5 times per day
It varies day to day, and it's not consistent
How many Calories do you consume daily?
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1000 or less calories per day
1000 - 1200 calories per day
1300 -1400 calories per day
1500 - 1600 calories per day
1700+ calories per day
I have no idea
What does your current nutrition look like on a daily basis?
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I eat random foods some healthy, some not (every day is different)
I'm intermittent fasting
I concentrate mostly on protein
I don't eat carbs
Just "eating healthy"
If you're currently following macros, where did you get them from?
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Personal Trainer
Online Calculator
Fitness App
I'm not following macros
What foods do you find your body tends to crave more of?
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Carbs (bread, pasta, pastries)
Sweets (sugars, candy, chocolate, ice-cream)
Salty (chips)
Fats (peanut butter, nuts)
I don't eat any of this
How often do you eat out
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I eat out 1x week
I eat out 2x a week
I eat out 3x a week
I eat out 4x a week
I eat out 5x a week
I eat out almost daily
I don't eat out
Please tell me what your daily nutrition (foods) currently looks like?
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Have you tried any of these methods?
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Cutting carbs
Jenny Craig
Weight Watchers
Whole30
Carnivore
Keto
Paleo
Mediterranean
Meal-replacement diets
Fasting
None of these
Other
What are you doing for cardio?
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None
I walk almost daily
I use the treadmill
I use the stairmaster
How long do you do cardio?
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10 minutes
15 minutes
20 -25 minutes
30 - 35 minutes
40 - 45 minutes
50+ minutes
Other
How many days per week are you doing cardio?
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1x
2x
3x
4x
5x
6x
7x
Other
Where do you workout?
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Gym
Home
Both
Other
How many days do you lift weights per week?
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I haven't started working out yet
1x week
2-3x week
4-5x week
6-7x week
Other
How long do you lift weights?
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I haven't started working out yet
20-30 minutes
45 minutes
60 minutes
90 minutes
Other
What does your lifting strategy look like?
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I lift with intension and have muscle groups broken down, reps, sets, rest periods.
I have specific muscle days broken down but no strategy behind them.
I lift random weights
I do whatever is comfortable that day
Other
How many hours of sleep do you get
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Less than 5 hours
6 - 7 hours
8 - 9 hours
10+ hours
Which symptoms have you experienced recently? Select all that apply.
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Fatigue
Brain Fog
Low energy
Mood swings
Poor sleep
Low libido
Hot flashes
Night sweats
Hair thinning
None of the above
Which best describes what you feel you need to achieve to feel more confident in your body?
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Lose about 5 lbs and build lean muscle
Lose 10 - 20 lbs and build lean muscle
Lose 30 - 40 lbs and build lean muscle
Lose 50+ lbs and build lean muscle
Tone up. My weight feels good but I want to look more toned
Just feel better overall and have more energy. (not worried about looks or scale)
Other
Are you taking any hormonal medications currently?
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HRT
No
Other
What are your biggest challenges you would like to fix? (click all that apply)
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Lose Weight/ Belly Fat
Gain Strength
Build Lean Muscle
Self Confidence
Balance Hormones
Fit into clothes again
Get off medication (thyroid, high BP, etc)
Lower stress (cortisol)
How do you currently feel about your glutes? (🍑butt) (click all that apply)
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I wish they were more round
I want to tighten them up
I want to get rid of the cellulite
I love how they look!
How long have you been trying to reach your fitness goals?
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1 month
2-3 months
4-6 months
1 year
2-5 years
5-10 years
What kind of timeframe do you want to reach these goals?
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Today
Next week
Next 3 months
Next 6 months
Not until next year
On a scale of 1-10 (10 being best how IMPORTANT is it that you reach your goals?
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It's ok if I don't
I'd like to make some small changes, I'm not exactly committed
It's pretty important, afraid to commit
I'm willing to try something different. I'm motivated!!
I'm fed up! I'm done doing the DIY, I need help!
In your own words, what would it take to get you EXCITED to start the actual strategy you need to get results?
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