First Name
Last Name
Phone
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Email
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Timeframe for Results
Less than 3 months
6 Months
6 Months - 1 Year
More than 1 year
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Tell me about yourself (your story, family, work, hobbies, etc)
Age/Height/Weight
What is your goal with regard to your diet? (Be as specific as possible) Example: weight loss, how much do you want to lose, build muscle, overall health
What are your health, fitness and nutrition goals? Please be specific
Gender
Female
Male
How would you rate your sleep quality/quantity?
1 = Poor, disrupted sleep
2
3
4
5 = Excellent, restful sleep
How would you rate your daily energy?
1 = Low Energy
2
3
4
5 = Super High Energy
How would you rate your daily cravings?
1 = No Cravings
2
3
4
5 = Out of control cravings
How would you rate your daily hunger?
1 = Never Hungry
2
3
4
5 = Always Hungry
How would you rate your daily mood?
1 = Not good, moody
2
3
4
5 = Excellent, no mood swings
What have you tried before that has and has not worked for you?
How long have you been pursuing your current goal?
Describe your current workout routine? (days per week, type of workout)
What did you do after your last diet?
List any other information I should know
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