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Last Name*
Phone*
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Birthdate
Biological Sex Male Female
Height (in feet and inches)
Weight (in pounds)
Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Ethnicity Hispanic or Latino Not Hispanic or Latino
Exercise/Activity Level (average daily physical activity) ---- Select One ---- Less Active (less than 30 minutes) Moderately Active (30-60 minutes) Active (more than 60 minutes)
Calorie Intake (average per day) ---- Select One ---- Under 1500 1501-2000 2001-2500 Over 2500
Sleep (average hours per night) ---- Select One ---- Less than 6 hours 6-8 hours Over 8 hours
Do you smoke and/or vape? ---- Select One ---- No Yes, 1-2 packs/cartridges per week Yes, 3-4 packs/cartridges per week Yes, more than 4 packs/cartridges per week Previously, but not currently
Stress Level (scale of 1-10, with 1 being low, and 10 being high)
Alcohol Intake (average per week) ---- Select One ---- None Yes, less than 1 drink per week Yes, 1-4 drinks per week Yes, 5-7 drinks per week Yes, more than 7 drinks per week
Do you follow a specific diet? ---- Select One ---- No Keto Intermittent Fasting Vegan/Vegetarian Carnivore Calorie Deficit Other (not listed here)
Caffeine Intake (average per day, 1 cup of coffee = approx 100mg, energy drinks vary) ---- Select One ---- None Up to 100mg 101-200mg 201-300mg Over 300mg
Allergens/Sensitivities (select all that apply) Peanuts Tree Nuts Seeds Gluten Oats Fish Shellfish Dairy Soy Eggs MSG Fruits (strawberry, banana, avocado, etc) Vegetables (celery, carrots, beets, etc) Seasonal allergies (hay fever, etc) Other (not listed here) No known allergens
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