Nutrition Questionnaire
First Name
Last Name
Email Address
Phone Number (if non-US phone number, please include country code)
Form Questions
In general, what are your goals?
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Out of all of the above concerns, which one feels most important/urgent and why?
What are you prepared to do to work towards your goals?
Have you tried anything in the past to change your habits, your eating, and/or your body? If so, what?
Which of those things worked well for you?
Which of those things didn't work well for you?
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Until now, what has blocked you or held you back from reaching your goals?
On a scale from 1-10, with 1 being "not at all" and 10 being "completely", how READY, WILLING, and ABLE are you to change your behaviors and habits?
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