Home
Packages
Virtual Sessions
Workout Plan
Meal Plan
Shopping List
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
*
Leave a comment (optional)
*
Submit
NYKR11-215
Home
Packages
Virtual Sessions
Workout Plan
Meal Plan
Shopping List