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Lifestyle Assessment Survey
Tell us a little more about you so we can work together on your goals!
51
Questions
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1
Your Name
*
This field is required.
First Name
Last Name
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2
Your E-mail
*
This field is required.
example@example.com
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3
Gender
*
This field is required.
Male
Female
N/A
Male
Female
N/A
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4
How Much Do You Weigh?
*
This field is required.
Ex: 150 pounds
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5
How Tall Are you?
*
This field is required.
Ex: 5'7 for 5 Feet 7 inches
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6
Your Date of Birth:
*
This field is required.
MM/DD/YYYY
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7
What Are Your Goals?
*
This field is required.
You may Select More Than One
Fat Loss
Muscle Gain
Improve Overall Health
Live A Healthier Lifestyle
Train For An Event or Sport
Learn More About My Body
Other
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8
What Service(s) Are You Interested In:
Online Accountability Coaching Program
Macro Based Nutrition Plan Only
Online Coaching & Macro-based Nutrition Plan
Metabolic Testing for body fat and metabolism (must be local to boca raton)
Other
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9
How Often Do You Weigh Yourself?
*
This field is required.
Never
Once a week
Two or Three Times a week
Every Day
Multiple times per day
Other
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10
Do You Have Any Medical Conditions
*
This field is required.
Yes
No
I don't know
Yes
No
I don't know
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11
If You Answered YES to Having Medical Conditions, Please Answer The Following:
Please List Any Known Condition.
Please List Any Prescriptions You Are Taking For These Conditions.
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12
What Diet or Lifestyle Methods Have You Tried?
*
This field is required.
Past & Current Methods Please
Paleo
Keto
Low Carb
Gluten Free
Vegan
Carnivore Diet
Atkins
None
Other
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13
If you selected OTHER, please tell us about the plan and how it worked for you:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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14
What Foods Do You Prefer?
*
This field is required.
Check All That Apply
Chicken and Turkey
Fish & Seafood
Beef & Pork
Beans, Legumes, Sprouts
Vegetables
Fruit
Dairy Milk, Yogurt , Cheese, Eggs
Non-Dairy Milk, Cheese, Yogurt
Other
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15
Are You Currently Tracking Your Calories?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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16
If YES, please list the app(s) you are currently using:
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Small
Ok
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Created with Sketch.
Ok
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17
How Many MEALS and SNACKS Do You Consume Per Day?
*
This field is required.
Please Select
1 Meal
2-3 Meals
3-5 Meals
5+ Meals
Please Select
Please Select
1 Meal
2-3 Meals
3-5 Meals
5+ Meals
How Many Meals?
Please Select
No Snacks
1 Snack
2-3 Snacks
3+ Snacks
Please Select
Please Select
No Snacks
1 Snack
2-3 Snacks
3+ Snacks
How Many Snacks?
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18
Do You Eat All Of Your Calories In One Meal?
*
This field is required.
Example: You eat once a day at 12 P.M.
Yes
No
Sometimes
Yes
No
Sometimes
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19
How Many of those Meals or Snacks are from Fast Food/Convenience Stores, Frozen, or "Heat & Eat"?
Please Select
1 Meal
2-3 Meals
3-5 Meals
5+ Meals
Please Select
Please Select
1 Meal
2-3 Meals
3-5 Meals
5+ Meals
How Many Meals?
Tell us Where It Comes From (Ex: Fast Food, Frozen etc)
Please Select
No Snacks
1 Snack
2-3 Snacks
3+ Snacks
Please Select
Please Select
No Snacks
1 Snack
2-3 Snacks
3+ Snacks
How Many Snacks?
Tell us Where It Comes From (Ex: Fast Food, Frozen etc)
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20
Do You Eat Breakfast?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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21
Do You Follow An Intermittent Fasting Schedule?
Example: Last meal by 7pm on Monday and your first meal is 11am on Tuesday
Yes
No
Sometimes
Yes
No
Sometimes
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22
If you follow an Intermittent Fasting Schedule, How Many Days Per Week And How Long Do You Fast?
Please Select
1-2 Days Per Week
3-5 Days Per Week
7 Days Per Week
Other
Please Select
Please Select
1-2 Days Per Week
3-5 Days Per Week
7 Days Per Week
Other
How Many Days?
Please Select
12 Hours
14 Hours
16 Hours
20 Hours
24 Hours
Other
Please Select
Please Select
12 Hours
14 Hours
16 Hours
20 Hours
24 Hours
Other
How Long?
If "OTHER", please explain.
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Perform Exercise In A Fasted State? (No food)
Please Select
Cardio
Weight Training
Both Cardio & Weights
Other
Please Select
Please Select
Cardio
Weight Training
Both Cardio & Weights
Other
If YES, What Type Of Exercise Do You Do Fasted?
If "OTHER" exercise, please explain.
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23
What Time Do You Usually Eat Dinner?
*
This field is required.
Ex: 7pm on Weekdays and 9pm on Weekends.
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24
Do You Snack After Dinner?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Snack After Dinner?
Please Select
Every Day
1-2 Days Per week
3-5 Days
Rarely
Never
Please Select
Please Select
Every Day
1-2 Days Per week
3-5 Days
Rarely
Never
How Often?
Please Select
Sweet
Salty
Carby
Oily/Fatty
Fruits or Veggies
Other
Please Select
Please Select
Sweet
Salty
Carby
Oily/Fatty
Fruits or Veggies
Other
What Kind Of Snacks Do You Go For?
If "OTHER", please explain.
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25
Do You Experience Food Cravings?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Get Cravings?
Please Select
Every Day
1-2 Days Per week
3-5 Days
Rarely
Never
Please Select
Please Select
Every Day
1-2 Days Per week
3-5 Days
Rarely
Never
How Often?
Please Select
Sweet
Salty
Oily/Fatty
Fruits or Veggies
Other
Please Select
Please Select
Sweet
Salty
Oily/Fatty
Fruits or Veggies
Other
What Do You Crave?
If "OTHER", please explain.
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26
Do You Drink Coffee?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Drink Coffee?
Please Select
1 Cup
2-3 Cups
4-5 Cups
5+ Cups
Other
Please Select
Please Select
1 Cup
2-3 Cups
4-5 Cups
5+ Cups
Other
How Many Cups Per Day?
Please Select
Sugar
Cream
Milk/Almond Milk
Oil or Butter
Other
Please Select
Please Select
Sugar
Cream
Milk/Almond Milk
Oil or Butter
Other
Do You Add Anything to your coffee?
If "OTHER", please explain.
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27
Do You Consume Energy Drinks?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Consume Alcohol?
Please Select
Once a month
1 per day
1 per week
2-3 per day
2-3 per week
4-5 per day
4-5 per week
5+ per day
5+ per week
Other
Please Select
Please Select
Once a month
1 per day
1 per week
2-3 per day
2-3 per week
4-5 per day
4-5 per week
5+ per day
5+ per week
Other
How Many Drinks:
Bang
Monster
Redbull
Celcius
Other
Bang
Monster
Redbull
Celcius
Other
What Brand?
If "OTHER", please explain.
To keep me awake
I like the taste
I hate Coffee
To keep from smoking or other drugs
Other
To keep me awake
I like the taste
I hate Coffee
To keep from smoking or other drugs
Other
Why Do You Use Energy Drinks?
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28
Do You Consume Alcohol?
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do You Consume Alcohol?
Please Select
1
2-3
4-5
5+
Other
Please Select
Please Select
1
2-3
4-5
5+
Other
How Many Drinks Per Week?
Wine
Beer
Mixed Drinks
Liquor
Other
Wine
Beer
Mixed Drinks
Liquor
Other
What Type?
If "OTHER", please explain.
Please Select
Yes
No
Sometimes
Please Select
Please Select
Yes
No
Sometimes
Do you use alcohol to cope with stress?
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29
Do You Smoke?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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30
If you do smoke, please tell us how many per day and frequency.
Ex: 1 pack of cigarettes every 3 days
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31
Do You Struggle With Making Healthy Choices or Preparing Meals?
Please Select
Yes I Struggle With Making Healthy Choices
No I Do Not Struggle With Making Healthy Choices
Yes I Struggle With Preparing Meals
No I Do Not Struggle With Preparing Meals
I Do Not Struggle With Any Of These
Please Select
Please Select
Yes I Struggle With Making Healthy Choices
No I Do Not Struggle With Making Healthy Choices
Yes I Struggle With Preparing Meals
No I Do Not Struggle With Preparing Meals
I Do Not Struggle With Any Of These
What Do You Struggle With?
Please Select
1
2-3
4-5
5+
Other
Please Select
Please Select
1
2-3
4-5
5+
Other
How Many Per Day?
Please Select
5 Hour Energy
BANG
Monster
Redbull
Celcius
Other
Please Select
Please Select
5 Hour Energy
BANG
Monster
Redbull
Celcius
Other
What Brand?
If "OTHER", please explain.
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32
Do You Have Any Past or Current Injuries?
*
This field is required.
Yes
No
I don't know
Yes
No
I don't know
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33
If You Answered YES to Having Injuries, Please Answer The Following:
Please List Any Known Injury and Body Part(s) Affected
Please List Any Prescriptions You Are Taking Or Treatments Done For These Conditions.
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34
Do You Exercise Currently?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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35
How Many Days Per Week Do You Exercise?
*
This field is required.
None
1-2
2-3
3-4
4-5
5-6
Every Day
None
1-2
2-3
3-4
4-5
5-6
Every Day
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36
What time of day do you usually exercise?
Early AM (4am-6am)
Morning (7am-10am)
Lunch time (11am-2pm)
Afternoon (3pm-5pm)
Late Evening (6pm-11pm)
other
Early AM (4am-6am)
Morning (7am-10am)
Lunch time (11am-2pm)
Afternoon (3pm-5pm)
Late Evening (6pm-11pm)
other
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37
If you exercise, please select what activities you do:
Strength Training
Cardio Training
Strength & Cardio Training
Pilates/Yoga
Power Walking
Other
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38
What type of exercise equipment do you have access to?
*
This field is required.
Please select all that apply. If OTHER, please explain.
Commercial Gym Equipment (Ex: LA Fitness, Planet Fitness)
Dumbbells or Kettlebells
Mini Resistance Bands
Cable Bands
Treadmill, Elliptical or Spin Bike
NONE
Other
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39
I Do Best With...
*
This field is required.
You may Select More Than One
Having a personal trainer
Participating in Group Fitness
Working out at home
Following a written program
Doing my own thing
Other
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40
Do You Struggle With Finding The Time or Motivation To Exercise?
*
This field is required.
Yes, finding the time
No, I find the time.
Yes, finding the motivation.
No, I'm plenty motivated
Yes, I struggle with both time and motivation.
Sometimes it's hard to find time.
Sometimes it's hard to find motivation.
Yes, finding the time
No, I find the time.
Yes, finding the motivation.
No, I'm plenty motivated
Yes, I struggle with both time and motivation.
Sometimes it's hard to find time.
Sometimes it's hard to find motivation.
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41
Do You Work?
*
This field is required.
Yes, full time. (40hrs per wk)
Yes, Part Time. (30 hrs or less per wk)
Not currently.
Retired.
Other.
Yes, full time. (40hrs per wk)
Yes, Part Time. (30 hrs or less per wk)
Not currently.
Retired.
Other.
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42
If you have a job, please select all that apply:
I work outside my home.
I work inside my home.
I work out of town.
Other
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43
What Shift Do You Normally Work?
Day Shift (9am-5PM)
Day Shift 12 Hrs (7am-7pm)
Afternoon Shift (3pm-11pm)
Night Shift (7pm-7am)
It Varies
Other
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44
Do You Get a Designated Lunch Break?
Yes
No
Sometimes
Yes
No
Sometimes
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45
Do You Enjoy Your Job?
Yes
No
Sometimes
Yes
No
Sometimes
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46
Please Indicate The Stress Level of Your Job Using The Slider:
*
This field is required.
Not Very
Not Very
Moderately
Very
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Not Very
Not Very
Moderately
Very
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
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47
What Time Do You Normally Go To Bed?
*
This field is required.
8-9 P.M.
10-11 P.M.
Midnight or later
It Varies
Other
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48
Do You Wake Up Multiple Times During The Night?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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49
If you do wake up, are you able to get back to sleep?
Yes
No
Sometimes
Yes
No
Sometimes
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50
Do You Feel Rested When You Wake Up?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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51
Do You Sleep with TV Screens or other bright lights on in your room?
*
This field is required.
Yes
No
Sometimes
Yes
No
Sometimes
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