Last Name
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First Name
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Email
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What is your age?
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Current Weight
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Do you have a weight range where you feel the best?
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What is your primary goal?
Lose 20+ lbs
Lose less than 10lbs and tone up
Performance (optimize my performance for a sport)
Build Muscle (build lean tissue to improve body composition and strength)
Health/Longevity (I want to live my life the best way possible. I want to feel my best!)
Aesthetics (I just want to look good naked! I have an event coming up I want to prepare for)
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Have you done any diets in the past? What were they?
How many calories were you eating on the diet per day? If not tracking, you can estimate?
How long were you on the various diets?
How many hours of sleep do you get per night?
How active are you?
Very sedentary (no exercise routine/desk job)
Sedentary (no exercise routine/minimally active during the day)
Moderately active (exercise 1-2x per week/about 5k steps per day)
Active (consistent exercise 2-3x per week/active throughout the day)
Highly active (physically demanding job/consistent exercise & 8-10k steps/day)
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For the following questions, rate yourself from 1-10 with 1 being 👎 BAD and 10 being 🙌 GOOD:
My cravings & hunger are managed... 1 is poorly 🍫 & 10 is great
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My energy level throughout the mid afternoon is...1 is low/crashing ⤵️ & 10 is high energy
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My protein in take is...1 is I don't know or less than 50g per day and 10 is 1g per lb of goal weight 🍗
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My food quality is...1 is not nutritious 🥮 and 10 is highly nutritious
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My ability to handle stress and challenges is...1 is not managing it well and 10 is managing it very well 🧘♀️
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My cravings and hunger are managed...1 is poorly managed 🤤 and 10 feels great
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I have daily normal and regular bowel movements...1 is not going to the bathroom every day or having GI issues and 10 normal 💩 1-3x per DAY
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When I try to lose weight, the results are...1 is terrible and 10 is fabulous 💃!
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I feel like I can manage my anxiety and tension....1 is not well and 10 rocking it 👯♀️!
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My immune system's response to potential infections is....1 is get sick all the time 🤧 and 10 is hardly ever sick, very healthy
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The clarity and vibrancy of my eye appearance is....1 is dull and 10 sparkly ✨
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My ability to manage my cravings for sugar / carbs is...1 is low, always crave things and 10 feels good and satisfied 😋
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My diagnosed food allergies or sensitivities are well managed....1 is have lots of them, feel crappy and 10 is not having any 🙌
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My mental clarity and focus are....1 is bad brain fog ("sorry what did you just ask?") and 10 is sharp on top of things 🧠
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The clarity and health of my skin is....1 is dry, spotchy, rosacea etc. and 10 is clear and smooth 😃
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The stability of my emotional mood is....1 is erratic ⇅ and 10 is stable
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My Management of my exposure to toxins and chemicals is....1 is I don't pay attention to it and 10 is I buy chemical free products 🌿
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The quality of my sleep is...1 barely sleep and 10 sleep like the dead 😴
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My Libido is...1 very low and 10 is sexy time 💞
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The total score for the 20 questions out of 200 is
This questionnaire is NOT about coaching, but are you interested in learning about how coaching could support your goals?
Yes I'm interested
I might be interested
Not interested right now
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