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Nutrition & Lifestyle Questionnaire
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Age
*
Weight (lbs)
*
Height (inches)
*
Sex
*
Male
Female
Inter
I want to
*
Eat for Health
Eat for Performance
Activity Level
*
Sedentary (little or no activity; desk job)
Lightly Active (Light exercise/ sports 1 – 3 days/ week)
Moderately Active (Moderate Exercise, sports 3 – 5 days/ week)
Very Active (Heavy Exercise/ sports 6 – 7 days/ week)
Extremely Active (Very heavy exercise/ physical job/ training 2 x/ day)
When do you typically work out
*
Early Morning
Mid Morning - Early Afternoon
Late Afternoon-Early Evening
Evening
Check All That Apply
*
Hypertrophy (body building style; multiple work sets/reps)
Strength (power lifting, strength sports)
Endurance (run, elliptical, bike, etc)
Low Intensity (yoga, walking, gardening, etc)
Sport Specific (specified performance goals for your sport that does not include strength sports)
Do you drink?
*
Yes, frequently (3+ drinks per week)
Yes, occasionally (1-3 per week)
No
Do you smoke?
*
Yes
No
Please list any dietary restrictions or allergies
*
Please list any lifestyle restrictions
*
Submit
Powerful Training
Martial Arts
Strength & Conditioning
Powerful People
Every Body Pulls
Heal. Flow. Grow.
LGBTQ+ BJJ Intro Class
Wellness for Small Business
Our Stories
Workshops & Courses
