Gold Survey NYKR11-215

Gold Questionnaire

* Indicates required field

Name *

email address *

Who recommended you? How did you hear about us? *

1.) Do you have any food allergies? *

Yes No

If yes please specify: *

2.) List foods you dislike: *

3.) On average, how many meals a day do you consume per day? *

1-2 3-4 5-6 7 or more

4.) On average, how many 8 oz. glasses of water do you drink per day? *

zero 1-3 4-6 7 or more

5.) On average, how many servings of fruits and vegetables do you consume per day? *

1-2 3-4 5 or more

6.) On average, how many servings of alcohol do you consume per week? *

0 1-2 3-5 6 or more

7.) List your comfort foods *

8.) How often do you eat out per week? *

never 1-2 3 or more

9.) How many meals are home cooked? *

none 25% 50% 75% 100%

10.) What is your cooking skill level *

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? *

none at least twice a week at least five times a week Everyday

12.) Do you take vitamins or supplements? *

Yes No

If yes, list items *

13.) Check all that implies on your health and fitness goals *

Gain Muscle Lose Fat Maintain Current Weight Get Ripped Improve overall Health

What's your Health and Fitness Goal *

What's your estimate height and weight? *

What is your target goal date? *