Fix My Diet!
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Height in inches
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Email
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Full Name
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Current Weight
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Do you have any medical conditions you wish to disclose? (I.E. diabetes, hypothyroid, high cholesterol, etc)
Goal Review Section
What is your primary fitness/weight loss goal?
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Weight Loss (less than 20 pounds)
Weight Loss (more than 20 pounds to lose)
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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What diets have you tried in the past?
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How many calories on average are you eating per day?(if not tracking, provide a rough estimate)
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What time do you eat your first meal?
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What time do you stop eating?
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How would you rate your protein intake?
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1: Barely eating protein
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10: Eating close to, at or above 1g of protein per pound of body weight (or protein with 2-3 meals/day)
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How would you rate your daily energy levels?
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1: Very low energy
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10: Very high energy
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How would you rate your food quality?
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1: Not paying any attention to what I am eating - poor food quality
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10: Eating green veggies at a minimum of 2 meals per day/80% whole foods
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Do you find yourself consuming large amounts of coffee or energy drinks to get through the day?
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How would you rate your daily stress levels?
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1: No stress at all
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10: Very high levels of stress
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How do you deal with stress?
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On average, how many hours of sleep do you get each night?
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6 or less hours
7 or less hours of sleep per night
7-9 hours of sleep per night
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How would you rate the quality of your sleep?
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1:Wake up several times a night/wake up tired
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10: Sleep like a rock/Very high energy upon waking
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Do you have a sleep routine (I.e. go to bed and wake up at generally the same time each day)
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Weekly structured activity, lifting weights, running, etc
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Very sedentary (no exercise routine/desk job)
Sedentary (no exercise routine/minimally active during the day)
Moderately active (exercise 1-2 days per week/about 5k steps a day)
Active (consistent exercise 2-3 days per week/active throughout the day)
Highly active (physically demanding job/consistent exercise or consistent exercise 4-5 days per week and 8-10k steps/day)
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How sedentary/active is your typical day?
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heavy labor all day (construction)
moderate (on feet/cashier - 5K-10k steps per day)
sedentary (sit most days - 5k or less steps)
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This assessment is not about coaching but are you interested in hearing more about 1 on 1 coaching?
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YES
NO
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