Lifestyle Assessment Form

Name(Required)

First Last

Instagram ID

Mobile(Required)

In case of emergency, call(Required)

Address(Required)

City Province

Date of Birth

Height

Weight Now

Weight Goal

Weekly Exercise Information

Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.

Exercise/Activity/Duration/Day Per Week

How would you rate the activity level of your profession, or what you do during the day (non-exercise related). Please circle.(Required)

Which best describes you?(Required)

Which of the following statements best describes your BODY TYPE?(Required)

I can eat practically anything I want and I don’t gain weight. I find it very hard to gain weight.

I can lose or gain weight by adjusting my activity level and eating habits.

I find it difficult to lose weight. I can gain weight easily and have to watch what I eat.

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also, show approximate amounts.(Required)

What time do you normally wake up?(Required)

What time do you normally go to bed at night?(Required)

How long does it take you to fall asleep?(Required)

If you smoke, how many per day?

If you smoke, how many years have you smoked?

What do you feel is your best accountability gauge for your desired goal:(Required)

Have you ever been placed on any type of nutritional program in the past? If yes, by whom and what did it consist of? Please explain below.(Required)

What were your results?

Family/Living Situation

Children(Required)

Occupation:(Required)

Have you lived or traveled outside North America?(Required)

Have you or your family experienced any recent life changes?(Required)

Have you experienced any major losses in life? Explain:(Required)

Are you or could you be pregnant?

Yes

Are you breastfeeding?

Yes

Are you pre-menopausal or menopausal?

Yes

What are the symptoms of your menopausal?

OTHER

Do odors bother you?

Have you had periods of binge eating or severe sugar cravings?

How do you deal with stress?

Name(Required)

First Last

Today's Date(Required)

Name*
First Last
Email*
Shipping Address*
Street Address Address Line 2 City Province Postal Code

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Cardholder Name
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Deep Dive Nutritional/Lifestyle Assessment Form

For Weight-loss, Muscle gain, Digestive health, Inflammation, Health concerns

Weekly Exercise Information

Family/Living Situation

Health Concerns

Do you eat or use, and how often?

How many cups of the following do you drink per day?

How many 1⁄2 cup servings of each do you typically eat in a day?

OTHER

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