Fitness Nutrition Program Assessment
Complete this assessment to help us design a personalized fitness nutrition program tailored to your needs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
What are your primary fitness and nutrition goals?
*
Weight loss
Muscle gain
Improved energy
Better overall health
Sports performance
Other
How would you rate your current physical activity level?
*
Not active
1
2
3
4
Very active
5
1 is Not active, 5 is Very active
Please describe your typical daily eating pattern.
*
Do you have any known allergies or medical conditions?
*
No known allergies or conditions
Food allergies
Medical conditions (e.g., diabetes, hypertension)
Other
List any supplements or medications you are currently taking.
How motivated are you to make changes to your nutrition and fitness habits?
*
1
2
3
4
5
Please rate your confidence in your ability to follow a nutrition program.
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
What are the biggest barriers or challenges you face in achieving your fitness and nutrition goals? (Select all that apply)
Lack of time
Motivation
Knowledge about nutrition
Access to healthy foods
Support system
Other
How would you rate your current nutrition habits in the following areas?
*
Rows
Fruit & Vegetable Intake
Water Consumption
Meal Regularity
Processed Food Intake
Poor
1
2
3
4
Fair
5
6
7
8
Good
9
10
11
12
Excellent
13
14
15
16
Submit Assessment
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