Goal Setting Name * First Name Last Name Message * Date of Birth * MM DD YYYY Height 4' 10" 4; 11" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 6' 0" 6' 1" 6' 2" 6' 3' 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11" 7' 0" Option Two If weight loss is a goal of yours, how many pounds would you like to lose? If you could grade your overall diet, what would it be? Grade A A- B+ B B- C+ C C- D+ D D- F Is there a specific event, target, or other date you have in mind for reaching your goal? If so, please describe. If you could grade your energy level, what would it be? A B C D F Please list some things in your life that may be holding your back from your healthy lifestyle you deserve. What are some items or activities in your life that you are willing to sacrifice to help reach your goal? Have you ever followed a nutrition plan? Yes No Do you regularly take vitamins or supplements? Yes No Have you ever followed a program and lost weight? Yes No Are you an emotional eater? Yes No Have you ever participated in personal training or group exercise? Yes No How would you rate your overall mood? Annoyed at most things and people Depressed Kinda Bla. Inconsistent Optimistic about each day Pumped up! How many hours of sleep do you get most nights? 10 9 8 7 6 5 4 3 2 1 Do you nap? If so, how many days a week? 1 2 3 4 5 6 7 How would you rate your overall stress level? Calm, cool, and collected. Almost no stress whatsoever. I am able to manage my stress well. I may have stress but I do not allow it to overtake my principles. For the most part, I'm cool, but I can snap with little provoking. I'm stressed. Most days. Every day is a ton of weight on my shoulders. It gets to me. It definitely changes my behavior. How many alcoholic beverages do you consume a week? 1 2 3 4 5+ How many energy drinks do you consume a week? 1-3 4-6 7-10 11+ When you are put to a challenge, are you someone who completes a mission? Yes No How many hours a week do you currently exercise? 1 2 3 4 5 6 7 8 9 10+ Thank you!
