Questionnaire (Gold Tier) First Name Last Name Email Sex Male Female 1) What are your specific wellness goals? 2) To the best of your knowledge, what is your current height and weight? 3) What is your goal weight? 4) What is your target goal date? 5) Please select any food allergies. None Milk Egg Peanut Shellfish Other If “Other,” please specify? 6) On average, how many meals do you consume per day? 1-2 3-4 5-6 7 or more 7) How many meals are home cooked? None 25% 50% 75% 100% 8) What is your cooking skill? None I can survive – 25% Others love my cooking – 50% – 75% Top chef – 100% 9) Which of the following breakfast items most interest you? Baby Spinach Omelet Fluffy Scrambled Eggs Greek Yogurt Blueberry Banana French Toast Apple Cinnamon Oatmeal Bowl Creamy Avocado Smoothie Other If “Other,” please specify: 10) Which of the following lunch items most interest you? Easy Apple Avocado Salad Caesar Salad BBQ Chicken Salad Carrot and Apple Soup Green Beans with Cherry Tomatoes Crab and Tuna Stack Other If “Other,” please specify: 11) Which of the following dinner items most interest you? Breaded Turkey Breasts Grilled Chicken Teriyaki Grilled Salmon Maple Glazed Turkey Roast Apple Butter Baked Beans Hearty Veggie Stir Fry Other If “Other,” please specify: 12) Which of the following snack items most interest you? Fresh Fruit Avocado Toast Homemade Granola Strawberry Banana Smoothie Strawberry and Oat Parfait Broiled Egg Other If “Other,” please specify: 13) Do you take any vitamins or supplements? Yes No If “Yes”, list items or condition(s): 14) Please select your age range: 18-39 40-59 60+ 15) Check all that applies on your health and fitness goals. Gain Muscle Lose Fat Maintain Current Weight Get Ripped Improve Overall Health Leave a comment (Optional) I agree to receiving marketing and promotional materials Send
