Questionnaire - Say NO To Diet

Welcome to your Start Now Form

Name

Email

What Are Your Goals? (tick all that apply)

weight loss weight gain tone up (weight distribution) build muscle mass be healthier have more energy better sleep better relationship with food other (write below)

What are the current barriers to reaching your goal?

time stress fatigue convenience family needs work other (write below)

What have you tried in the past? What worked? What didn’t?

How active are you?

sedentary moderately active active very active

How motivated are you?

1 2 3 4 5 6 7 8 9 10

What are your favourite foods: loves, likes, maybes and hard-nos?

Do you have allergies? What are they?

Any surgical procedures? List here:

What prescription medications do you take?

What non-prescription medications do you take? (Vitamins, supplements, etc.)

Do you smoke, vape or drink alcohol? How often, how much?

Do you or have you had any of any of the following? (check all that apply)

hypertension heart problems injuries cancer gas bloating constipation insomnia anxiety depression addiction diabetes crohn’s disease kidney issues irritable bowel syndrome (IBS) menopause migraines acid reflux joint pain lethargy fatigue other (write below)