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Questionnaire
First Name
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Last Name
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City
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ZIP / Postal Code
Email Address
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Phone Number
Age
How did you hear about our programs?
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Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, etc)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (if that is part of your goal)
Medical Questions
Are you pregnant?
Yes
No
Unsure
Are you nursing?
Yes
No
How old is your baby?
Do you have any of the following?
Diabetes- Type 1
Diabetes- Type 2
High Blood Pressure
Kidney Disease
Thyroid Disease
Do you have any food allergies or dietary restrictions?
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Blood Thinners
Other
What other reason are you taking medication for?
Sleep
How many hours of sleep do you typically get per night?
How is your quality of sleep? Do you rise feeling rested?
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Other
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)
Do you currently exercise? Ifo so, how many times a week?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Would you like to learn how to earn free PartnerCo products or money with this company?
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