Client Questionnaire

Welcome to Energized Nutrition! Filling out this quick questionnaire will help us design a customized plan just for you. We will contact you within 24 hours regarding a free-first-consultation. The information provided will help us design an energy plan just for you. We will provide you with a 21-Day-Transformation-Guide to reprogram your genes based on Nutrition, Exercise, Sleep and Stress-Management.

I: About You

	Answer
What is your age?

What is your occupation?

How many hours do you work or attend school/day?

How many hours do you sleep/night?

How many meals do you eat/day?

How many days/week do you exercise?

II: Current Health Issues

	Issue
1

2

3

4

III: What are your health goals? (The next 30-days, The next 6 Months)

IV: What's inspiring you to make this change now?

V: How do you feel?

VI: Exercise

	Describe
Describe your exercise patterns in the past 10 years

Is working-out something that you enjoy?

If so, what types of exercise do you enjoy?

Are you currently exercising consistently? How much?

VII: Food

	Describe
Do you have any known allergies to food, vitamins or minerals?

What are you favorite foods to eat?

Is shopping an investment or a chore?

VIII: Personal

	Describe
How do you prefer to communicate (e-mail, text, phone, face-to-face)

Have you used any specific Diets/Plans in the past? (please list)

Are you familiar with the Paleo Lifestyle?

On a scale of 1-10 how important is it for you to optimize your nutrition?

Thank you for the information. We look forward to helping you live the most energized life possible. Please list your methods of contact in the table and we will contact you within the next 24 hours.

	Contact
Phone Number

E-Mail

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