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NUTRIFIT
Lifestyle Habits Questionnaire
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How many hours of sleep do you get per night, on average?
*
4 or less
4 - 6
6 - 8
8 - 10
10+
Which of these statements describes you? (you can chose none or more than 1)
I struggle to fall asleep
I wake up few times per night but fall back asleep easily
I wake up in the middle of the night and struggle to fall asleep
I wake up in the morning feeling tired I wake up in the morning feeling tired
I am tired all the time
How many hours per week do you exercise? (excluding going for a walk)
Less than 1
1 - 3
4 - 6
7+
Which statements describe you the best? ( you can chose more than 1 )
I like to eat small frequent meals
I eat 3 meals per day
I eat big dinners
I skip breakfast
I eat all the time
What is your relationship with alcohol like ? (you can chose more than 1)
I drink daily
I am a social drinker
I binge drink occasionally
I don’t drink
When do you feel most productive?
Early morning
Mid morning
Lunch time
Afternoon
Evening
How many hours per day do you spend on social media, mainstream tv and online browsing and shopping?
Less than 30 min
30 min - 2 hours
2 - 4 hours
4hours +
Which of these statements describe you the best? (you can chose more than 1)
I love a challenge
I love routine
I'm scared of failing
I can't change
I want to change
How stressed do you feel on scale 1-10?
Selected Value:
1
Please fill in the worst consequence you can imagine for not improving your habits: “If I don’t change my lifestyle habits I will...
Name
*
First
Last
Email
*
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