Questionnaire (Platinum 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? 3) To the best of your knowledge, what is your current weight? 4) What is your goal weight 5) What is your target goal date? 6) Please select any food allergies. None Milk Egg Peanut Shellfish Other If “Other,” please specify? 7) On average, how many meals do you consume per day? 1-2 3-4 5-6 7 or more 8) How many meals are home cooked? None 25% 50% 75% 100% 9) What is your cooking skill? None I can survive – 25% Others love my cooking – 50% – 75% Top chef – 100% 10) 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: 11) 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: 12) 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: 13) 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: 14) Do you take any vitamins or supplements? Yes No If “Yes”, list items: 15) Do you smoke? Yes No 16) How many days can you workout? 1 2 3 4 5 6 7 17) What is your exercise level? Beginner Intermediate Advanced 18) Please select your age range: 18-39 40-59 60+ 19) Do you have any condition that would require a doctor’s clearance? Yes No If “Yes”, please specify: 20) Do you experience any of the following during physical activity? Loss of balance Dizziness Loss of consciousness Chest pains Shortness of breath None 21) Do you have an existing or previous injury that may affect how you perform physical activities? Upper Body Lower Body None If “Yes”, please specify: 22) Are you prescribed medication for blood pressure or a heart condition? Yes No If “Yes”, please specify which condition: 23) Are you, or have you recently been pregnant? Currently Pregnant Recently Pregnant Neither 24) Do you have access to a gym? Yes No List gym equipment that you have at home. 25) 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
