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Gold Questionnaire
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Indicates required field
Name
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email address
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Who recommended you? How did you hear about us?
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1.) Do you have any food allergies?
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Yes
No
If yes please specify:
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2.) List foods you dislike:
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3.) On average, how many meals a day do you consume per day?
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1-2
3-4
5-6
7 or more
4.) On average, how many 8 oz. glasses of water do you drink per day?
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zero
1-3
4-6
7 or more
5.) On average, how many servings of fruits and vegetables do you consume per day?
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1-2
3-4
5 or more
6.) On average, how many servings of alcohol do you consume per week?
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0
1-2
3-5
6 or more
7.) List your comfort foods
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8.) How often do you eat out per week?
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never
1-2
3 or more
9.) How many meals are home cooked?
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none
25%
50%
75%
100%
10.) What is your cooking skill level
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don't know how 0%
I can survive 25%
Others love my cooking 50-75%
Top chef 100%
11.) How much time are you willing to set aside for meal prep?
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none
at least twice a week
at least five times a week
Everyday
12.) Do you take vitamins or supplements?
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Yes
No
If yes, list items
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13.) Check all that implies on your health and fitness goals
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Gain Muscle
Lose Fat
Maintain Current Weight
Get Ripped
Improve overall Health
What's your Health and Fitness Goal
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What's your estimate height and weight?
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What is your target goal date?
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Leave a comment (optional)
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Who recommended you? How did you hear about us?
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Submit
NYKR11-215
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