Efitphany Program Questionnaire

Thank You For Your Order

Please complete this form. This gives us an understanding of where you are currently so that we can help you succeed long term.
Full Name

First NameLast Name
Gender
Age
Cell Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail
Current weight
What was your weight at age 18?
What was your highest adult weight & age at the time
What was your lowest adult weight & age at the time?
Height
Build/Frame
I would like to lose___. Please note this is your LONG TERM goal. Select one.
Do you currently exercise?
If yes please list what activities you currently do and how often
Where will you be working out?
Do you drink alcohol?
If so, how many glasses per week?
My body's worst problem areas are?
Have any members of your immediate family also experienced weight gain?
How many Hours of sleep do you get nightly
Glasses of water you consume per day?
What is your stress level?
Have you had
Do you experience
You have concerns about the safety of exercise? Please write here
Other illnesses/conditions you think we should know about? Please list them here
List all vitamins, natural remedies and supplements you are currently taking
Please Check Any Allergies or Foods You Do Not Eat
What would your typical breakfast consist of?
What would your typical lunch consist of?
What would your typical dinner consist of?
What are your snacks of choice?
Quality of Nutrition Life Questions (check all that apply)

Lifestyle Changes

Rows	Not Very	Somewhat	Very Much
How Important is it to you to make lifestyle changes
How ready are you to make lifestyle changes
How confident are you that you can do it

Thank You For Your Order