Client Assessment Questionnaire

Let's get to know YOU before we create your plan.

Thank you for choosing Smart Wellness Canada. We're excited to create meal plans tailored just for you!

This short questionnaire collects basic info about your health, preferences, and lifestyle.

Rest assured:
Your responses are securely stored and used only to design your custom plans.

We never share your data with third parties...it's just between us to support your wellness goals.

Please take 3–5 minutes to complete it. Your delicious, stress-free meals are waiting!

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1. Full name (First and last name) (Required.)

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2. Email address (Best email to send your plans and any follow-up questions) (Required.)

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3. What Wellness Program are you purchasing? (Required.)

Thrive Through Menopause (all Inclusive program)

Nutrition for Menopause (Meal Plan only)

Midlife Wellness Coaching Session

Unsure: would like to book a Free Discovery Call

Other (please specify)

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4. What is your age? (Required.)

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5. What is your gender? (Required.)

Male

Female

Non-binary

Prefer not to say

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6. What is your current height? (Required.)

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7. What is your current weight? (Required.)

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8. If purchasing our Thrive Through Menopause program, how would you like to receive your weekly motivational messages from our team?

Text: we will ask for phone number only after program is purchased

I would like to opt out of the weekly messages

Not applicable

Other (please specify)

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9. Daily Activity Level (select one) (Required.)

Sedentary (desk job, little to no exercise)

Lightly active (light exercise/sports 1-3 days/week)

Moderately active (moderate exercise/sports 3-5 days/week)

Very active (hard exercise/sports 6-7 days/week)

Extremely active (very hard exercise, physical job, or 2x training)

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10. Do you have any food allergies or intolerances? (Select all that apply)

Dairy

Gluten

Nuts

Shellfish

Soy

Eggs

Other (please specify)

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11. Are you currently taking any medications or have any medical conditions we should be aware of when creating your meal plan? (Please list medications, diagnosed conditions, or notes such as diabetes, high blood pressure, IBS, Crohn’s, celiac, high cholesterol, etc.)

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12. Do you follow (or prefer to follow) any particular way of eating? (Select all that apply)

Vegetarian

Vegan

Pescatarian

Gluten-free

Dairy-free

Low-FODMAP

Mediterranean-style

No pork

Halal

Other (please specify)

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13. What are your “hard no” foods? (Foods you strongly dislike or do not want included under any circumstances.)

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14. What are some of your favourite foods or flavours you’d love to see in your meal plan? (List a few favourite meals, ingredients, cuisines—e.g., Mexican, Italian, soups, bowls, one-pan dinners.)

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15. What is your primary health goal? (Required.)

Weight-loss

Reduce inflammation

Support gut health

Better sleep

More energy

Hormone balance/menopause support

Blood-sugar balance

Other (please specify)

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16. What does a typical day of eating look like for you right now? (Roughly describe when and what you usually eat for breakfast, lunch, dinner, and snacks.)

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17. Which best describes your cooking style?

Quick and Simple

Comfortable with Basic recipes

Happy to try more Involved meals

Other (please specify)

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18. How many people should this meal plan be designed for?

Just me

Me and one other person

Me and 2–3 other people

Me and 4 or more people

Not applicable: purchasing consultations only

Other (please specify)

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19. How have past meal or diet plans worked for you?
Feel free to share what you liked about them, and what didn’t really work or fit your lifestyle.

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20. Is there anything else we should know before creating your meal plan? (Share any extra details that would help us make this plan realistic for your life.)

Important Health Disclaimer
Before starting any new dietary plan or making significant changes to your nutrition, please consult your physician or qualified healthcare professional, especially if you have existing medical conditions, are pregnant, or take medications. Smart Wellness Canada provides general wellness guidance only and is not a substitute for personalized medical advice. Your health comes first!

Client Assessment Questionnaire

Let's get to know YOU before we create your plan.

Question Title

* 1. Full name (First and last name) (Required.)

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* 2. Email address (Best email to send your plans and any follow-up questions) (Required.)

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* 3. What Wellness Program are you purchasing? (Required.)

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* 4. What is your age? (Required.)

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* 5. What is your gender? (Required.)

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* 6. What is your current height? (Required.)

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* 7. What is your current weight? (Required.)

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* 8. If purchasing our Thrive Through Menopause program, how would you like to receive your weekly motivational messages from our team?

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* 9. Daily Activity Level (select one) (Required.)

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* 10. Do you have any food allergies or intolerances? (Select all that apply)

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* 11. Are you currently taking any medications or have any medical conditions we should be aware of when creating your meal plan? (Please list medications, diagnosed conditions, or notes such as diabetes, high blood pressure, IBS, Crohn’s, celiac, high cholesterol, etc.)

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* 12. Do you follow (or prefer to follow) any particular way of eating? (Select all that apply)

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* 13. What are your “hard no” foods? (Foods you strongly dislike or do not want included under any circumstances.)

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* 14. What are some of your favourite foods or flavours you’d love to see in your meal plan? (List a few favourite meals, ingredients, cuisines—e.g., Mexican, Italian, soups, bowls, one-pan dinners.)

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* 15. What is your primary health goal? (Required.)

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* 16. What does a typical day of eating look like for you right now? (Roughly describe when and what you usually eat for breakfast, lunch, dinner, and snacks.)

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* 17. Which best describes your cooking style?

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* 18. How many people should this meal plan be designed for?

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* 19. How have past meal or diet plans worked for you?Feel free to share what you liked about them, and what didn’t really work or fit your lifestyle.

Question Title

* 20. Is there anything else we should know before creating your meal plan? (Share any extra details that would help us make this plan realistic for your life.)

1. Full name (First and last name) (Required.)

2. Email address (Best email to send your plans and any follow-up questions) (Required.)

3. What Wellness Program are you purchasing? (Required.)

4. What is your age? (Required.)

5. What is your gender? (Required.)

6. What is your current height? (Required.)

7. What is your current weight? (Required.)

8. If purchasing our Thrive Through Menopause program, how would you like to receive your weekly motivational messages from our team?

9. Daily Activity Level (select one) (Required.)

10. Do you have any food allergies or intolerances? (Select all that apply)

11. Are you currently taking any medications or have any medical conditions we should be aware of when creating your meal plan? (Please list medications, diagnosed conditions, or notes such as diabetes, high blood pressure, IBS, Crohn’s, celiac, high cholesterol, etc.)

12. Do you follow (or prefer to follow) any particular way of eating? (Select all that apply)

13. What are your “hard no” foods? (Foods you strongly dislike or do not want included under any circumstances.)

14. What are some of your favourite foods or flavours you’d love to see in your meal plan? (List a few favourite meals, ingredients, cuisines—e.g., Mexican, Italian, soups, bowls, one-pan dinners.)

15. What is your primary health goal? (Required.)

16. What does a typical day of eating look like for you right now? (Roughly describe when and what you usually eat for breakfast, lunch, dinner, and snacks.)

17. Which best describes your cooking style?

18. How many people should this meal plan be designed for?

19. How have past meal or diet plans worked for you?
Feel free to share what you liked about them, and what didn’t really work or fit your lifestyle.

20. Is there anything else we should know before creating your meal plan? (Share any extra details that would help us make this plan realistic for your life.)