AMAR - Lifestyle and Performance consultancy survey

Your Information - Contact
Full Name*
First
Contact Phone*
Please use international format e.g. +34 XXX XXXX XXX
Email*
Age
Preferred Contact Method
- Phone call
- Email
- Meeting (face to face)/Zoom/Skype
Gender
- Male
- Female
- Prefer not saying
Preferred day of Consultation
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Preferred Time of Consultation (please provide a time window)

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More Information about you / Medical History and Medication
Please list any relevant past medical history and current medications.
Reason for Consultation / Diet Planning request - you may mention worrying habits (food or non food related)*
Current Body Weight (use desired unit - kg/gr/lb/st)
10 year weight range
Height (use desired unit cm/mt/inc/feet)
Are you currently on any sort of medication that affects your eating choices/habits?
- Yes
- No
Kindly provide more details on the medication and how it affects you?
In your past experience with food and diet, what are common challenges you've had?
Which of the below have been Barriers to improving your Diet and Eating habits, in the past?
- Time
- Money
- Children
- Motivation
- Lack of Education
Do you commonly experience Mental / Brain fogginess? Or feel a lack of orientation during your day.
- No
- Yes

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Goal Setting
Which of the following physical activity do you commonly practice (include any that you are considering performing in the coming 6 months aswell)
- Stretching / Yoga
- Cardio / Aerobics
- Strength Training / Weight Lifting
- Team sport
- Swimming
- Tennis or Racket sport
- Tai Chi
- Rollerblade
- Hiking
- Pilates
- Dance
- Running
Does anything limit you from being physically active? If Yes, please give details
- No
Describe your overall health goals including any habits you would like to improve or eliminate.
Three months from today, how would you like to be described as?
- Lighter having lost some body fat
- Heavier with more muscle mass
- Indifferent
- Sronger with better dietary stability and better nutritional choices
- Energetic and much efficient with work
To improve your health, how willing are you to:
On a scale of 1 (not willing) to 5 (very willing), please indicate your willingness to do the following below:
Significantly modify your diet
- 1
- 2
- 3
- 4
- 5
Take nutritional supplements each day
- 1
- 2
- 3
- 4
- 5
Modify your lifestyle (eg. work demands, sleep habits, physical activity)
- 1
- 2
- 3
- 4
- 5
Practice relaxation techniques
- 1
- 2
- 3
- 4
- 5
Engage in regular exercise / physical activity
- 1
- 2
- 3
- 4
- 5
Any further comments to add?
What strategy do you prefer when making changes?
- Going Cold Turkey - meaning, I'm confident I can adapt to sudden intensive change
- Taking it steady - meaning, I prefer small changes over a long period of time
- I'm unsure
Would you be willing to fill out a 3 day Food Journal for a future consultation?
- Yes - please send it to me
- No
Do you have any questions and or comments you would like to add? Please add here:
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We believe that ‘healthy lifestyle’ is a flexible concept. Each one of us has different needs, however, we should be able to pick up a product without ever worrying about reading labels. We intend to empower each other with the ability to craft our own personally enriched experience of lifestyle, through food, and food for thought.

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