Name *

First Name

Last Name

Phone *

(###)

###

####

How would you describe your current diet? *

(Check all that apply)

Balanced (includes a variety of food groups)

Vegetarian

Vegan

Low-carb/Low-fat

Gluten-free

Dairy-free

Other (please specify)

How often do you eat meals/snacks throughout the day? *

1-2 meals per day

3 meals per day

3 meals + snacks

I tend to skip meals often

How would you rate your current energy levels? *

Very low

Lo

Moderate

High

Very High

How often do you exercise each week? *

Never

1-2 times per week

3-4 times per week

5+ times per week

What type of exercise do you typically do? *

(Check all that apply)

Cardio (running, cycling, etc.)

Strength training (weights, resistance bands, etc.)

Yoga or Pilates

Walking or hiking

Other (please specify)

How would you rate your sleep quality? *

Very Poor

Poor

Fair

Good

Excellent