Name *

First Name

Last Name

What is your sex? *

Male

Female

How would you describe your current activity level? *

Sedentary

Lightly active

Active

Very active

Can you walk for 20 mins straight? *

Yes

No

How confident are you in your current eating habits? *

Not confident

Somewhat confident

Very confident

What are you most excited to improve? *

Nutrition

Movement

Habits

Mindset

Metabolism

How would you describe your current eating habits? *

I skip meals regularly

I eat mostly processed or takeout food

I try to eat healthy but struggle with consistency

I eat well most of the time

I follow a specific diet (e.g. keto, vegan, intermittent fasting)

What’s your biggest nutrition challenge right now? *

I don’t know what to eat

I struggle with emotional eating or cravings

I eat late at night

I don’t have time to cook

I get overwhelmed with nutrition rules

I’m doing well—I just need structure

On average, how many meals do you eat per day? *

1

2

3

4 or more

How confident are you in knowing what to eat for fat loss? *

1 = Not confident at all 5 = Very confident

1

2

3

4

5

Injuries/Limitations *

Yes

No