Bad A$$ Challenge BAD A$$ CHALLENGE 15th July- 24th Sep(Required)BAD A$$ CHALLENGEJULY 15 - 24TH SET 2022Welcome to your preliminary and exclusive nutritional questionnaire . Excuted by clinical dietitian & nutritionist Vicky Gomez from Healthy Empire in Collaboration with Fit2box Boxing Studio. The purpose of this questionnaire is to assist us in setting up your own personalized meal plan. This will help set you up for success and help us maximize your results over the 10 week BAD A$$ CHALLENGE .Todays Date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920First Name(Required) Last Name(Required) Mobile(Required) Email(Required) DOB(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Dietary Requirements? Vegan, Plant Based or Vegetarian(Required) Religious requirements ?(Required) Work Life- What are your hours(Required) Casual: Part Time: Full Time: Shift work: Not working Other What type of work do you do?(Required) Office Worker: Labourer: Other Is lunch prepared or purchased(Required) Prepared Purchased Do you ever feel tired or fatigued throughout the day?(Required) Yes No What time of the day Do you feel most fatigued?(Required) Home life- Living arrangements?(Required) Live alone, Live with others, how many residents. Number of children/ dependents?(Required) Are you the main cook?(Required) Yes No Are you primary food shopper?(Required) Yes No How often do you have take away?(Required) What is your choice of take away food?(Required) How many times per week do you have take away food?(Required) What are some of your favorite cuisines?(Required) What results are you looking for out of this challenge?(Required) Weightloss Weight gain Muscle gain Maintenace Increase energy levels Control health conditions What type of exercise do you do?(Required) How many days per week?(Required) What level of intensity is your exercise?(Required) On a scale of 1-10 with 10 been the hardestHave you expirenced weightloss or gain in the past 3-5 years(Required) Yes No If any what have been your most recent weight management (loss/gain) strategies?(Required) 3 Day diet eating history(Required) Day 1: Day 2: Day:3Please some of the foods will you or can not eat?(Required) 1: 2: 3: 4: 5:What are some of your favourite foods?(Required) 1: 2: 3: 4: 5:What time of the day do you find it the hardest to stick to your eating plan?(Required) Morning Mid Morning Lunch Time After lunch (Mid afternoon) Dinner After dinner Before bed Mid night Select AllHow much alcohol do you drink per week?(Required) I do not drink alcohol I am a casual drinker 1-3 drinks per week 4-6 drinks per week 7-10 drinks per week 10+ drinks per week Select AllThank you for taking the time to fill out this questionnaire, the information provided is confidential to Fit2box and body by Vicky Gomez. Information will be used to formulate your eating plan. I agree to allow uf to use this information to help you on your weightloss journey. Yes No Δ
