PowerPlay Lifestyle +Nutrition Questionnaire
You are about to begin your PowerPlay Lifestyle questionnaire! This is a really important part of the process, so it is important that you set aside some time to answer these questions. The more thorough you are, the more we will be able to help YOU! We will be asking you a number of questions to get to know you, your lifestyle, and your goals for the future.  We are so excited you have decided to join our team!
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Email *
Name *
Phone number *
Height *
Weight *
Age *
Gender
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What is your goal for joining our program? *
Are there any specific milestones you are hoping to achieve? And timeline for that milestone? *
Below are a list of nutrition/fitness lifestyle goals. Please check all that apply *
Required
What is your most persistent nutrition/fitness related obstacle? *
Have you noticed the situations that trigger poor food choices? *
What are you looking for in a lifestyle coach that we can do to best support you during this process? *
What is your vision of success? *
What does a typical day of nutrition currently look like? (Please do not “sugar coat” your response. We are looking for an honest and real representation of your intake. If possible, include total calories, carbs, protein, and fats. If unknown, list your food intake – type and amount – for a typical day) *
How often do you make trips to the grocery store/get grocery delivered? *
How often do you eat out (at restaurants or delivery)? *
Which of the following best describes how you feel about cooking your own food? *
Do you currently prepare any of your food for the week ahead of time? *
How often do you drink alcoholic beverages?
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Have you ever weighed and measured your food using a scale? *
If yes, how confident do you feel in weighing and measuring your food? *
Have you ever used a food tracking app before? (ex. MyFitnessPal, MyMacros+) *
When you look at a food item, would you know if it consisted primarily of carbs, fats, or protein?
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Do you have any allergies or dietary preferences? (ex. Vegan, vegetarian, paleo, etc.) *
Do you use any supplements or medications (including birth control)? If so, please list. *
Which of the following best categorizes your style of exercise? Select all that apply. *
Required
How often do you workout in a typical week? *
What is the activity level of your occupation? *
What does your work/school schedule look like?
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Are you the primary caregiver in your household? (For children, individuals with a disability, or elderly relatives)
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How many hours do you sleep on a typical night? *
How would you rate your sleep quality 1-10 (10 being best)? And Why? *
Have you dieted or worked with a nutrition coach in the past? If so, what has worked best for you to achieve your goals? *
Do you or have you ever suffered from any medical illnesses? If so, what was the treatment, and are you still undergoing treatment or taking medication for it? *
Do you or have you ever suffered from any type of eating disorder? If so, what was the treatment and are you still undergoing treatment for it? When was the last episode?
Are you pregnant? Or have you been pregnant in the past six months? If so, what is your due date? And which pregnancy (first child? Second? Etc.)
Are you currently breastfeeding? Or have you been breastfeeding in the past six months?
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What is your Facebook name? If you have one, let us know so we can add you to a private group of your fellow program mates!
Do you have a preference to work with a Male or Female coach?
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Anything else you’d like us to know? Questions, Comments, Concerns?
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