Efitphany Program Questionnaire

Thank You For Your Order

Please complete this form. This gives us an understanding of where you are currently so that we can help you succeed long term.
Full Name*

First NameLast Name
Gender

FemaleMale
Age*
Cell Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail*
Current weight*
What was your weight at age 18?
What was your highest adult weight & age at the time
What was your lowest adult weight & age at the time?
Height*
Build/Frame
I would like to lose___. Please note this is your LONG TERM goal. Select one.*

1-10 lbs11-15 lbs15-20 lbs21-25 lbs25+ lbs
Do you currently exercise?*

YesNo
If yes please list what activities you currently do and how often
Where will you be working out?

GymHome
Do you drink alcohol?*
If so, how many glasses per week?
My body's worst problem areas are?

CalvesWaistThighsKneesStomachChestHipsNeckBottomUpper Arms
Have any members of your immediate family also experienced weight gain?
How many Hours of sleep do you get nightly

Less than 5 hours5-7 hours7+ hours
Glasses of water you consume per day?
What is your stress level?

LowMediumHigh
Have you had

Heart AttackHeart SurgeryCardiac CatherisationCoronary AngioplastyPace makerHeart Valve DiseaseHeart TransplantHeart FailureCongenital Heart DiseaseTake heart medicationDiabetes
Do you experience

Chest discomfort with exertionUnreasonable breathlessnessDizziness, fainting or blackouts
You have concerns about the safety of exercise? Please write here
Other illnesses/conditions you think we should know about? Please list them here
List all vitamins, natural remedies and supplements you are currently taking
Please Check Any Allergies or Foods You Do Not Eat

GlutenHoneyMayoEggsPeanutSoyTofuShellfishBreakfast CerealPastasBreadRiceOatmealSugarBeansLentilsPeasPotatoes & YamsCornArtichokeAsparagusBeetsBrocolliCarrotsSproutsCeleryPeppersTomatoEggplantAvocadoAlmondsWalnutsPecansMilkCreamCheeseYogurtCottage CheeseApplesBananaGrapesOrangeStrawberriesRaspberriesBlueberriesBeefPork/BaconLambVealChickenTurkeySalmonTunaTilapia
What would your typical breakfast consist of?
What would your typical lunch consist of?
What would your typical dinner consist of?
What are your snacks of choice?
Quality of Nutrition Life Questions (check all that apply)

I Was Hungry Between MealsEnjoyed Food Without GuiltSneaked FoodCooked Most of My MealsLiked The Way My Clothes FitBeat Myself Up Over My EatingTook Time For MyselfWas Confused About What I Should EatRewarded Myself With FoodWas Happy About The Food I AteFelt That Food Was Controlling MeCreated Stress With Family & Friends Over My Food NeedsWas Nagged By Family & Friends About The Food I AteHad Someone I Could Talk To Who Understands My Food StrugglesFound It Difficult To Stick With How I Should Eat While With Family & FriendsFelt Confident I Could Trust Myself With Difficult Food ChoicesWanted To Change My Eating Habits For Good

Lifestyle Changes

	Not Very	Somewhat	Very Much
How Important is it to you to make lifestyle changes
How ready are you to make lifestyle changes
How confident are you that you can do it

What things make it hard for you to make lifestyle changes?
Your Goals
Are You Ready To Do This?

YesHeck Yes
Should be Empty:

Thank You For Your Order