12 Week Custom Nutrition Questionnaire | Performance360

Lifestyle & Goals Assessment:

Tell us about your goals and what you hope to achieve with your nutrition. Be specific.

PERSONAL INFORMATION:
Full Name*
Best Email:*
Are you a current Performance360 member?*
- Yes
- No
How do you identify?*
How old are you?*
How tall are you and how much do you weigh?*
What pre-existing medical conditions do you have? This can include past injuries, surgeries, diseases, and other medical considerations. (Keep in mind that you will need to seek the permission of your doctor to follow this program, and any advice we give you should never be considered professional medical advice.)*
Do you work at home?*
Do you have young kids at home?*
How many hours per week do you work?*
Do you have the flexibility to control your nutrition?*
With how much accountability do you thrive?*
What kind of coaching style do you prefer?*
Which best describes your level of nutrition knowledge?*
Do you have any specific nutritional needs? Such as, “I am a vegan” or any food allergies?*
GOAL SPECIFIC INFORMATION
Which would you say your goals skew mostly towards?*
How important is it for you to lose weight?*
How many pounds do you hope to lose?
How important is it for you to add muscle?*
What are some common hurdles that have prevented you from reaching your goals before?*
As your Coach, what should I be most aware of about you as a Client? It’s okay, there is no judgement here. This helps me better serve you.*
Tell me about your goals. Be specific.*
PERSONAL HABIT INFORMATION
How many hours per week of sleep do you get each night?*
How much water are you currently drinking each day?*
On the average day, how are your stress levels?*
How many meals per week would you say you prepare at home?*
How many full meals do you eat per day?*
How much protein would you say you eat?*
Tell me about a typical day of eating for yourself. Be honest, there is no judgement.*
GOALS DISCOVERY
This will help us get to the base level root of your needs.
Why are you interested in doing this?*
Why is that important to you?*
What will that matter, ultimately?*

PERSONAL INFORMATION:

GOAL SPECIFIC INFORMATION

PERSONAL HABIT INFORMATION

GOALS DISCOVERY