Diet With Me - 12 Week Client Questionnaire

Select your Motivation Level *

Name *

Email *

Gender *

Age *

Height *

Weight *

How much weight are you trying to lose? *

Is there a specific deadline for achieving your weight loss goal? (If yes, please enter goal date) *

Approximately how many calories are you currently eating? (If known) *

Have you tried losing weight in the past? How recently? *

If so, what approaches have you tried? E.g. diet plans, exercise programs *

What has prevented you from achieving this goal in the past? *

Why are you motivated to lose weight now? What’s different? *

Why do you think this is the right program for you? *

What type of activities or exercise do you currently do? *

What MUST you achieve after this experience? *

Questions/Comments (Please feel free to ask any questions or share anything else that may be relevant!) *

Diet With Me – 12 Week Client Questionnaire