Birthday

What do you want to change? Pick 3*

On average do you eat....*

On average do you drink....*

Dietary Preferences *

Cooking Abilities*

On average how many times a week do you eat out?*

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Do you feel pain in your chest when you perform physical activity?*

In the past month, have you had chest pain when you were not performing any physical activity?*

Do you lose your balance because of dizziness, or do you ever lose consciousness?*

Is your doctor currently prescribing an medication for your blood pressure or for a heart condition? Is your doctor currently prescribing an medication for your blood pressure or for a heart condition?*

Are you currently pregnant?*

Do you have diabetes or thyroid condition?*

Do you know of any reason why you should not engage in physical activity?*

Do you plan to become pregnant in the next three months?*

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

If you answered yes to any of these questions, have you been medically cleared by your doctor?*

Date