Clean Eats Start Up Questionnaire

To help me better understand each participant’s needs during this Challenge, please answer the questions below. Your answers will remain anonymous. The questions and answers provided during this program may be used for statistical data.

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Name: *
Today's Date *
What prompted you to take this Challenge? *
How did you learned about this Challenge? *
What are some things you hope to get out of this Challenge? *
At this time I want to learn more about... (check all that apply) *
adding more nutritious foods to my dietplanning healthier mealseliminating wheat and processed foods from my dietusing food to decrease medicationslosing weight without a restrictive dietimproving my energy and vitalityfeeling better in general (less aches, pains & fatigue)nothing in particular
I identify my gender as... *
How old are you? *
At the beginning of this Challenge, I feel I am in... *
I am... *
What medications are you taking at the time of this Challenge? *
Please share what you eat in a typical day for breakfast, lunch, dinner and include typical snacks. *
How many hours of sleep do you usually get at night? *
How much water did you drink daily before taking this Challenge? *
What are your main health concerns (if any)? *

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Eat smart • Move more • Feel better • Live longer

Clean Eats Start Up Questionnaire

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