Platinum Survey NYKR11-215

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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 applies to 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 current (estimate) height and weight? *

What's your goal weight? *

What is your target goal date? *

14.) Do you have any current or previous heart conditions? *

Yes No

15.) Do you smoke? *

Yes No

16.) Do you have any bone or joint issues? *

Yes No

If yes, explain: *

17.) What's your exercise level? *

Beginner Intermediate Expert

18.) Are you over the age 65? *

Yes No

19.) Do you have any conditions that would require a Doctor's clearance? *

Yes No

If yes, explain *

20.) Do you lose balance, get dizzy, or lose consciousness during physical activity *

Yes No

21.) Do you experience chest pain or shortness of breath during physical activity? *

Yes No

22.) Are you prescribed medication for blood pressure or a heart condition? *

Yes No

23.) Are you, or have you recently been pregnant? *

Yes No

If yes, please describe *

24.) Do you have access to a gym? *

Yes No

25.) List gym equipment that you have at home *

NYKR11-215

Contact Us

Terms of Service

Privacy Policy

Available Positions

Home
Packages
- Virtual Sessions
Workout Plan
Meal Plan
- Shopping List

Questionnaire

NYKR11-215

Contact Us

Terms of Service

​Privacy Policy

Available Positions

Privacy Policy