This information is a great help in assisting me in creating the optimal plan best suited for your individual needs. Please answer as accurately and honestly as possible.
Name: {"type":"text","name":"__generic","width":40,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Age: {"type":"text","name":"__generic","width":10,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Gender: Male Female {"type":"checkbox","name":"__generic","width":30,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Male\nFemale"} {"type":"text","name":"__generic","width":30,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"Feet & inches"} {"type":"text","name":"__generic","width":15,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":"lbs"} {"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Sleep
How many hours of sleep do you get on average per night?
{"type":"text","name":"__generic","width":15,"value":"","size":"Normal","validation":"TN","validationMessage":"Please fill in this item.","placeholder":"hours"}
Do you have trouble falling asleep or staying asleep? Most of the time Some of the time Almost never {"type":"checkbox","name":"__generic","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Most of the time\nSome of the time\nAlmost never"}
Do you feel rested when you wake up?
Rarely Occasionally Mostly {"type":"checkbox","name":"__generic","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Rarely\nOccasionally\nMostly"} Stress
How would you rate your stress levels on a scale from 1-10?
12345678910{"type":"select","name":"__generic","width":10,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}
Rank your top 3 sources of stress (First = most, Last = least){"type":"text","name":"__generic10","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
How do you typically cope with stress?{"type":"textarea","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Nutrition
How many meals do you typically eat per day? {"type":"text","name":"__generic","width":10,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""} Do you currently follow any specific diet or nutritional plan? - If so what's it called? {"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"Paleo? Keto? Vegan? Etc?"} Have you previously tried any specific diet or nutrition plan? - If so what's it called?{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"Paleo? Keto? Weight watchers? Other? "} How often do you eat out? 0-1 x/ week 2-3 x/ week 4-5 x/ week 6+ x/ week {"type":"checkbox","name":"__generic","width":30,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"0-1 x/ week\n2-3 x/ week\n4-5 x/ week\n6+ x/ week"}
Eating Habits Do you binge eat? If so, how often? {"type":"text","name":"__generic","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Do you engage in emotional eating? Rarely (once a month maybe) Occasionally (1-3 times per week) Frequently (almost daily) {"type":"checkbox","name":"__generic","width":30,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Rarely (once a month maybe)\nOccasionally (1-3 times per week)\nFrequently (almost daily)"}
Do you often eat socially or in social settings? Yes No {"type":"checkbox","name":"__generic","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Do you have a sweet tooth? A bad one A mild one Not really {"type":"checkbox","name":"__generic","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"A bad one\nA mild one\nNot really"}
Physical Activity How often do you work out each week? Never Rarely (maybe once ever other week) Occasionally (maybe once a week) Regularly (2-3 times per week) Routinely (4-7 times per week without fail) {"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Never\nRarely (maybe once ever other week)\nOccasionally (maybe once a week)\nRegularly (2-3 times per week)\nRoutinely (4-7 times per week without fail)"}
What types of exercise do you do?{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
How long are your workout sessions? None 5-15 minutes 15-25 minutes 25-45 minutes 45-90 minutes {"type":"checkbox","name":"__generic22","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"None\n5-15 minutes\n15-25 minutes\n25-45 minutes\n45-90 minutes"}
Do you enjoy working out? No, I despise it I tolerate it Actually kinda like it Love it, gotta have it {"type":"checkbox","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"No, I despise it\nI tolerate it\nActually kinda like it\nLove it, gotta have it"}
Smoking and Drinking Do you smoke? If so, how much and how often? {"type":"text","name":"__generic","width":35,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Do you drink alcohol? If so, how much and how often? {"type":"text","name":"__generic","width":35,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Social Connection Do you feel you have a strong social support network? Not really, would love more support Not bad but could use work Yes, it's pretty good Absolutely! {"type":"checkbox","name":"__generic","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Not really, would love more support\nNot bad but could use work\nYes, it's pretty good\nAbsolutely!"}
How often do you engage in social activities? {"type":"text","name":"__generic","width":45,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Relationship and Job/Career Satisfaction What is your current relationship status? Happily single Happily engaged in a relationship Not quite so happily single Not quite so happily engaged in a relationship {"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Happily single\nHappily engaged in a relationship\nNot quite so happily single\nNot quite so happily engaged in a relationship"}
What is you current job/career status? Eh, pays the bills Counting down the days till i leave Some days are a drag, but I generally enjoy my role Retired, stay-at-home, or just don't work {"type":"checkbox","name":"__generic","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Eh, pays the bills\nCounting down the days till i leave\nSome days are a drag, but I generally enjoy my role\nRetired, stay-at-home, or just don't work"} What is your current job title? {"type":"text","name":"__generic","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""} Spiritual Satisfaction Do you feel fulfilled spiritually? {"type":"text","name":"__generic","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Do you engage in any spiritual or mindfulness practices? {"type":"text","name":"__generic","width":35,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Supplementation and Medications Do you take any supplements? If so, which ones?{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Are you on any medications? If so, please list them.{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Health and Regularity How regular are your bowel movements? Very regular - 1 or more BM per day 4-6 BM per week 2-3 BM per week 1 or less BM per week {"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Very regular - 1 or more BM per day\n4-6 BM per week\n2-3 BM per week\n1 or less BM per week"}
Do you have any chronic health conditions or concerns?{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Daily Schedule What time do you typically wake up? {"type":"text","name":"__generic","width":15,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What time do you typically go to bed?{"type":"text","name":"__generic","width":15,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Motivation and Goals (Please don't hold back - the more into the better!) Why do you want to lose weight or get healthier?{"type":"textarea","name":"__generic40","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What is your main motivation for making this change?{"type":"textarea","name":"__generic41","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How do you see your life changing once you achieve your goals?{"type":"textarea","name":"__generic42","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are the top two goals you want to achieve with this program?{"type":"textarea","name":"__generic43","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What has held you back from achieving these goals in the past?{"type":"textarea","name":"__generic44","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Additional Information Is there anything else you would like us to know about you or your lifestyle?{"type":"textarea","name":"__generic45","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
