Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Age
Birth Date
*
MM
DD
YYYY
Gender
*
Male
Female
Height
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4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
Current Weight (lbs)
*
Preferred/Target Weight (lbs)
*
Do you have any medical history with the following? (Check all that apply)
*
Please list any prescription medications you take with dosage and frequency below separated by commas. If you do not take any medications, please type 'None'.
*
Please list any over the counter medications you take with dosage and frequency below separated by commas. If you do not take any medications, please type 'None'.
*
Do you have food allergies?
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If yes, please list all allergies below separated by commas. If you don't have any, type 'None'.
*
Do you have any dietary restrictions (i.e. vegitarian, vegan, gluten-free, etc.)?
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If yes, please describe below.
Please list any sugrcal procedures you have experienced. If you have not had any, please type 'None'
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Do you consider yourself:
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Sedentary
Lightly active (sporadic workouts, lawn work, active lifestyle)
Moderately active (exercise 1-2 days/week)
Highly active (exercise 3+ days/week)
Do you believe you are physically fit?
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No
Less than average
Average
Above average
Outstanding
Checkbox 1
*
What are your main reasons for participating in a training program (select all):
Please list the 3 most important characteristics of highly successful people:
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Please list the 3 most important factors of why people experience failures:
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Achieving your training or athletic goal is:
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90% mental/10% physical
50% mental/50% physical
10% mental/90% physical
Are you afraid of failure?
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Are your nutritional goals specific towards (check all that apply):
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How many times do you eat per day (including meals and snacks)
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1-2
3-4
5-6
6+
What is the frequency of your meals?
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1-2hrs
3-4hrs
5-6hrs
6+hrs
Do You Skip Meals
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If you skip meals please explain why.
On a weekly basis, how often do you dine out or bring food in for LUNCH?
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0-1x
2-3x
4-5x
6-7x
On a weekly basis, how often do you dine out or bring food in for DINNER?
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0-1x
2-3x
4-5x
6-7x
When you dine out, which options best describe your most common dining environment?
*
Do you ever experience the following when you consume Fatty foods, spicy foods, acidic foods or alcohol:
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Are you currently following a "diet"?
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If so, which diet have you been following and how long have you been following it?
How closely did you follow the diet on a scale of 1-10, with 10 being the most.
1
2
3
4
5
6
7
8
9
10
What are your favorite indulgences and how often do you enjoy them?
How much water do you consume daily? Please note there are 128 oz in a gallon.
*
What other liquids do you drink on a regular basis (at least 3x per week)?
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What weight management strategies have been SUCCESSFUL for you in the past?
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What weight management strategies have been UNSUCCESSFUL for you in the past?
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Do you take any nutritional supplements?
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If yes, what nutritional or dietary supplements do you take?
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What is your driving force behind eating?
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Please list your typical intake for a weekday BREAKFAST. Please be as detailed as possible.
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Please list your typical intake for a weekday LUNCH. Please be as detailed as possible.
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Please list your typical intake for a weekday DINNER. Please be as detailed as possible.
*
Please list your typical intake for a weekday SNACKS. Please be as detailed as possible.
*
Please list your typical intake for a weekend BREAKFAST. Please be as detailed as possible.
*
Please list your typical intake for a weekend LUNCH. Please be as detailed as possible.
*
Please list your typical intake for a weekend DINNER. Please be as detailed as possible.
*
Please list your typical intake for a weekend SNACKS. Please be as detailed as possible.
*
If you’ve participated in program before, what were your previous kcals for meal plan?
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1400
1500
1600
1700
1800
2000
over 2000
I don't know
I'm a new participant
How satisfied were you with your hunger level?
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Always hungry
Barely satisfied
Satisfied
Very satisfied
It was too much to eat
I am a new participant
Did you predominantly follow:
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Meal plan
'The 12 rules for success'
Both
Neither
If you followed the meal plan, how compliant were you?
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Perfect – no indulgences
Very good – 1-2 indulgences per week
Good – 3-4 indulgences per week
Fair – 5-6 indulgences per week
Poor – 7 or more indulgences per week
N/A - I am a new participant
If you did not follow the Meal Plan, please provide a reason
What challenges, if any, were there to following the meal plan completely?
Do you have any recommendations or suggestions for us regarding you nutritional experience?
Please provide any additional information that you believe is important for us to know.
