First Name
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Last Name
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Email
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Phone
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What are your primary goals?
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Lose Weight
Maintain Weight
Improve Body Composition
Other
What motivates you to achieve these goals?
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How committed are you to reaching your goals? (Scale of 1-10, with 10 being fully committed)
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How often do you typically work out each week?
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0-1 times
2-3 times
4-5 times
6+ times
What type of workouts do you currently do? (e.g., strength training, cardio, yoga, group classes, etc.)
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What are your biggest nutritional challenges?
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Alcohol Consuption
Family Meals
Sweets & Desserts
Emotional Eating
Parties & Social Gatherings
How much sleep do you usually get per night?
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Less than 5 hours
5-6 Hours
7-8 Hours
More than 8 hours
Do you feel that stress affects your eating or exercise habits?
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Yes, a lot
Somewhat
Not really
How do you plan to handle tempting meals?
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I plan to stick to my usual eating habits as much as possible
I'll try to make healthier choices, but still plan to indulge a bit
I plan to fully enjoy without restriction
Do you have a strategy for staying active?
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Yes, I'll stick to my current workout routine
I'll try to exercise when I can, but it it may be less than usual
I don't currently have a plan for staying active
On a scale of 1-10, how confident are you in your ability to achieve your goals? (1 = Not confident at all, 10 = Extremely confident)
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What is one thing you would like to accomplish?
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Do you currently follow a structured nutrition plan?
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Yes, strictly
Yes, but flexible
No, but I try to make healthy choices
No, I eat what I want