Fitness journy
Health & Nutrition survey
1.Name
*
First Name
Last Name
2.Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
3.Are you interested improve your health.?
*
Yes
No
Other
4.Do you Belive Nutrition and Health are related.?
*
Yes
No
Other
5.Which of words best describe your lifestyle.?
*
Active
Calm
stressed
Other
6.Do you think you will get 100% daily Nutrition need.?
*
Yes
No
Sometimes
Other
7.Do you take any Nutritional supplements.?
*
Daily
Sometime
Never
Other
8.Do experience a loss of energy during the day.?
*
Yes
No
Occasionaly
Other
9.Do you consider Yourself.?
*
Overweight
Underweight
Ideal
10.Would you like to lose/gain extra weight & learn control your weight.?
Lose
Gain
Type option 3
Type option 4
Submit
Should be Empty: