Personalized Meal Plan Questionnaire

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* 1. Contact information

First & Last Name

Email Address

Phone Number

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* 2. What is your diet goal? What aspect of your nutrition would you want to improve on? Why? (e.g, for health, weight loss, muscle gain, etc.)

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* 3. Please fill in the information below at the best of your ability (if applicable).

Current weight (lbs)

Goal weight (lbs)

Activity level (14-16 scale) *14=sedentary, 16=very active

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* 4. Do you know how many calories/macros you should be eating per day? If so, what is it?

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* 5. On a scale of 1-10, how would you rate your Nutrition? *1=very poor, 10=excellent

1

5

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. For how long would you like my guidance? *$15 + $10/week

Only the Meal Plan ($15)

1 week ($25)

2 weeks ($35)

3 weeks ($45)

4 weeks ($55)

4 Weeks+ ($55 + $10 x # of desired weeks). Please specify how many weeks.

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* 7. Do you understand that I am NOT a certified nutritionist and that my service is solely based on my experience and personal research?

Yes

No

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* 8. Would you be comfortable with making your transformation public? (e.g, allowing me to post you on my social media).

Yes

No

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* 9. Anything else I should know or want to tell me? (Budget, food intolerance/allergies, food you abstain from, etc). *Please state specific food allergies/intolerances or abstain from.