Lifestyle Questionnaire

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This form is meant to give us a better Idea about your health and nutrition.

Please fill this out and get it back to us asap.
All answers are confidential and will not be seen by eyes other than Ashton and Chantal to determine if our program is the right fit for you.

Name *

Email *

Phone Number *

Preferred Pronouns *

He/Him

She/Her

They/Them

Other:

What do you struggle with most? What would you like help with? *

Nutrition

Fitness

Mindset and confidence

All of the above

Other:

Required

How physically active are you currently? *

Sedentary (office job)

Light Exercise (1-2 days a week)

Moderate Exercise (3-5 days a week)

Heavy Exercise (6-7 days a week)

Athlete (2X per day)

What type of physical activity do you consider fun? *

Are there any previous health issues that we should be aware of? ( This would include surgeries, heart conditions etc.) *

What is your current relationship with food? Pick all that are applicable *

I feel guilty about eating

I avoid or restrict foods that are “bad” for me

I have developed a long list of rules surrounding the foods I can and cannot eat

I have a history of yo-yo dieting or following the latest diet fads

I feel immense stress and anxiety when eating in social settings due to fear of what others may think of my food choices

I find myself restricting and/or binging food

None of the above

Required

On a typical week, how is your food prepared? *

Cook most of my own meals daily

Meal prepping boss

Eat out / Take out kind of person

I don't cook at all

Other:

What is your current diet? *

Vegan

Vegetarian

Standard American Diet

Pescatarian

Other:

Hypothetical question- Let's say you started to work with a coach to learn how to become healthier, fitter and confident. After finishing up working with the coach, you were asked to rate the experience on a scale of 1-10. You gave the experience a 10/10. What would have happened working with that coach to lead you to rate the experience highly? *

If you found a coach that you wanted to work with to help you reach specific weight or fitness goals, and to work with that coach required an investment, how would you fund that investment? *

I have access to savings

I would use a credit card

I would use revenue from my business

I would use income from another job

I would never invest in a coaching program

Required

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