Health and Lifestyle Questionnaire

Get to know someone's habits before designing a plan: eating patterns, energy, exercise, weight goals and any condition to keep in mind. The final question asks permission to call and continue the conversation. Very handy for wellness coaches and nutrition programmes.

Use this template

Already have an account? Log in

Name*

Nombre

Apellido

Phone Number*

Do you consider your diet balanced?

Yes, I believe so No, my diet is unbalanced I am not sure

How would you rate your energy levels?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

What is your goal?

Lose weight Gain weight Maintain my current weight Build muscle

How much weight would you like to lose or gain?

Less than 5 kilos Between 5 and 10 kilos Between 10 and 20 kilos More than 20 kilos

How often do you exercise?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Do you have any health condition we should know about?

Yes, there is something to share No, none Prefer not to say

May we call you with more information about the programme?*

Yes, you may call me No, thank you I would rather get a message

Related templates

Acne Questionnaire Healthcare Acupuncture Booking Form Healthcare Acupuncture Consultation Form Healthcare Acupuncture Informed Consent Form Healthcare

Browse all questionnaires templates →

Powerful online forms — builder, logic, products, and teams — at a price that makes sense.

Product

Features
Pricing
Compare
Alternatives
Templates
Claude
API
GitHub

Company

Press room
Brand kit
Contact

Legal

Terms of service
Privacy policy
Cookie policy

Rejoining the server...

Rejoin failed... trying again in seconds.

Failed to rejoin.
Please retry or reload the page.

The session has been paused by the server.

Failed to resume the session.
Please retry or reload the page.