Personalized Nutrition & Lifestyle Questionnaire

Thank you for taking the time to complete this questionnaire. Your responses help us tailor your nutrition and lifestyle plan—grounded in science and personalized for you.

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Tell us about yourself…

First and Last Name

First Name

Last Name

What do you want to be called (i.e. nickname?)

First Name

Last Name

Date of Birth

YYYY

Phone

Country

(###)

###

####

Food Tracking

If you're using a nutrition tracking app, please share your username and password here (you can reset it after our work together):

Lifestyle Goals

In your own words, how do you think we can best help you with your nutrition and lifestyle goals?

Height

We ask for your height, current weight, and goal weight to help personalize your plan and track progress toward your lifestyle goals safely and effectively.

Weight

Goal Weight

Medical and Health History

Are you currently experiencing or have you experienced any of the following conditions? (Check all that apply)

Eating Habits & Patterns

Please share your habits for each of the following:

Physical Activity Habits

“It all begins with an idea. Maybe you want to launch a business. Maybe you want to turn a hobby into something more. Or maybe you have a creative project to share with the world. Whatever it is, the way you tell your story online can make all the difference.”

— Squarespace