Questionnaire
Please fill out your Questionnaire
Name
Email
Phone Number
What is your primary nutrition goal? (Select all that apply)
Weight Loss
Weight Gain
Muscle Building
Maintenance
General Health Improvement
Other (please specify):
Are you currently following any specific diet or nutrition plan?
Yes
No
If yes, please describe:
if yes
What type of diet do you prefer?
What type of diet do you prefer?
- Vegetarian
- Vegan
- Mediterranean
- Standard Eating (eats everything)
- Other (please specify):
Are you open to trying new foods within your chosen diet plan?
Yes
No
Maybe, depending on the food
Do you have any food allergies or intolerances?
Yes
No
If yes, please list:
If yes:
How many meals do you typically eat per day?
1-2
3-4
5+
Are there any foods you dislike or want to avoid? (Please list)
Multiple Checkboxes
Sedentary (little to no exercise)
- Lightly active (light exercise or physical activity)
- Moderately active (exercise 3-4 times a week)
- Very active (exercise 5+ times a week)
- Extremely active (athlete or heavy physical labor)
Do you take any supplements or vitamins?
Yes
No
Do you have any medical conditions we should be aware of (e.g., diabetes, high blood pressure,
Yes
No
Submit