Metabolic Reset Questionnaire
Please complete this questionnaire to help assess your current metabolic health and readiness for a metabolic reset program.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Do you have any of the following health conditions? (Select all that apply)
*
Diabetes or pre-diabetes
High blood pressure
High cholesterol
Thyroid issues
None of the above
Other
How would you rate your current energy levels?
*
1
2
3
4
5
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
1
2
3
4
5
Brain fog
6
7
8
9
10
Cravings for sweets
11
12
13
14
15
Difficulty losing weight
16
17
18
19
20
Digestive issues
21
22
23
24
25
How many days per week do you exercise (at least 30 minutes)?
*
0 days
1-2 days
3-4 days
5 or more days
How would you describe your typical eating habits?
*
Mostly healthy, balanced meals
Frequent takeout or processed foods
Irregular meal times
Skip meals often
Other
On average, how many hours of sleep do you get per night?
*
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
How would you rate your current stress levels?
*
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
What is your primary goal for participating in a metabolic reset program?
*
Weight loss
Increase energy
Improve digestion
Better sleep
Other
Are you ready to make changes to your lifestyle habits to support your metabolic health?
*
Yes, I am ready
I am considering it
Not at this time
Is there anything else you would like to share about your health or goals?
Submit Questionnaire
Should be Empty: