Intake Questionnaire
Select your gender
–
Male
Female
What is your age?
What is your height?
What is your CURRENT weight?
What is your CURRENT body fat percentage? You may also type "unknown"
What is your CURRENT activity level?
–
Sedentary (office job)
Light Exercise (1-2 days/week)
Moderate Exercise (3-5 days/week)
Heavy Exercise (6-7 days/week)
Athlete (2x per day)
How much time do you spend exercising CURRENTLY?
–
30 mins or less
30-60 mins
60-90 mins
More than 90 mins
Currently, I do not exercise
Where do you prefer to exercise?
–
Gym
Outside
Home
Other
Is exercise equipment available to you? If so, what?
What type of exercises do you do currently? For example: weightlifting, running, bodyweight workouts, etc. You may also state "none"
What is your main fitness goal? You may state more than one. Example: Lose/Gain 10 pounds and get stronger, etc.
Have you tried any workout programs in the past? If so, please let us know which ones and share your experience.
How many days a week are you willing to / would like to work out?
–
1
2
3
4
5
How many minutes are you willing to / would like to work out?
–
30 or less
30 - 60
60 - 90
Have you tried any diets or nutrition plans in the past? If so, please let us know which ones and share your experience.
Do you have a nutrition plan currently?
–
Yes, I count calories and/or macronutrients.
Yes, I am currently dieting.
No, I don't, but I eat healthily.
No, I eat randomly.
Which of the following best describes your current eating?
–
I eat completely randomly
I eat healthily sometimes
I eat healthily most of the time
List any dietary restrictions. Such as vegan, vegetarian, etc. You may also state "none"
How often do you consume "junk" foods? Such as cookies, chips, sodas, ice cream, candies, honey buns, cake-like treats, milkshakes, or other similar items. (Please answer with how many times per day, week, or month)
How often do you eat "fast food" or "take-out"? (Please answer with how many times per day, week, or month)
How often do you consume fruits or vegetables? (Please answer with how many times per day, week, or month)
How often do you consume foods high in protein? Such as chicken, eggs, fish, beef, yogurt, tofu, etc. (Please answer with how many times per day, week, or month)
Do you consume any food/nutritional supplements? Such as multivitamins, protein shakes, creatine, meal replacement bars, etc. (Please SPECIFY THE TYPE and how many times per day, week, or month)
Are you currently using any supplements that target "fat loss", such as GLP1, thermogenics, appetite suppressants, injected compounds, etc.? (Please SPECIFY THE TYPE)
Do you have / ever had any eating disorders? Please share your experience.
Are you willing to track your eating for 48 hours? (This assists our approach to the upcoming changes to your eating)
–
Yes
No
What are some challenges that might hinder your progress?
What motivates you most to reach your goals?
*List any medical limitations that may interfere with your participation in exercise or nutritional programs. (optional)
Name (First & Last)
Email
Phone Number (optional)
Submit
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