Personalized Macro Assessment Questionnaire

Let’s Get Started!

Submitting the form will trigger me to get to work calculating your personalized macro targets. I recommend that you set aside about 15-20 uninterrupted minutes to provide a detailed picture of your health.

NOTE: Once you submit this questionnaire, the link for purchasing your starter packet is provided in the sent confirmation notice.

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Name *

First

Last

Email *

What is your sex? *

• Male
• Female

I use sex to help better calculate energy needs because of hormonal differences between males and females. Please select the choice that feels most appropriate for your body.

How old are you? *

How tall are you in inches? *

What is your current weight in pounds? *

This is important for setting macro goals accurately, though it might not be a motivating factor for you and your goals. Please provide your actual weight or your closest guess.

Current Goal? (Select One) *

• Lose Weight
• Build Muscle (You’d Like to build muscle & increase your overall body weight)
• Athletic Performance (You want optimal nutrition to support long & intense athletic training)
• Body Recomposition (You want to lose fat & simultaneously build muscle; scale does not change as fast)
• Improve Heath (You want to improve your nutrition & overall Health, while maintaining your current weight)

If the goal you selected is to lose weight, what is your goal weight? *

If this is not applicable, please enter 000

Estimated goal weight completion date? *

If this is not applicable, please select current date

If the goal you selected is to build muscle, what is your goal weight? *

If this is not applicable, please enter 000

Estimated goal weight completion date? *

If this is not applicable, please select current date

Weekly Purposeful Exercise (Select One) *

• Very Light (Almost no purposeful exercise)
• Light (1 to 3 hours of gentle to moderate exercise)
• Moderate (3 to 4 hours of moderate exercise)
• Intense (4 to 6 hours of moderate to strenuous exercise)
• Very Intense (7 + hours of strenuous exercise)

Daily Activit Level EXCLUDING Weedkly Purposeful Exercise (Select One) *

• Very Light (Sitting most of the day, i.e. desk job)
• Light (Mix of sitting, standing & light activity i.e. teacher)
• Moderate (Continuous gentle to moderate activity i.e. restaurant server)
• Heavy (Strenuous activity throughout the day i.e. construction worker)

Please explain your reasons for deciding to request a personalized macro packet. *

If you’ve tried free calculators or macro based nutrition programs in the past, please describe what you did or did not enjoy about the experience. If you have worked with Empower Fitness & Wellness in the past, please describe what you’ve been doing since we ended our work together.

Optional: Attach progress pictures here. Great progress pictures are ones taken from the front, side and back. Women are dressed in "fitted" clothing, preferably a sports bra and shorts. Men are dressed in "fitted" clothing, preferably shorts.

Click or drag files to this area to upload. You can upload up to 4 files.

Please list what you do for exercise, if any, and how much time you spend being active during a typical week. If you have a typical weekly routine or schedule, please list the routine here. *

Do you know, on average, how many steps per day you take outside of your formal exercise? This is usually determined with a step counter like a FitBit, Garmin, Apple Watch, etc.

Are you currently tracking macronutrients? If yes, please list the macro goals that you've been prescribed. Please indicate either your current protein, fat or carbohydrate gram goals or macro percentages. *

Please indicate whether or not you have trouble hitting your prescribed macro goals. Which macro, if any, do you go over on or fall short of in a typical week and why?

Please rank how close you've been able to hit your macro prescription over the last 4 to 6 weeks?

• I have at least attempted to track my macros every day and I am certain I have been able to hit my macros within 5 grams +/-
• I have at least attempted to track my macros every day and I am certain I have been able to hit my macros within 10 grams +/-
• I have been successful some of the time when tracking and I am hitting my macros as prescribed some of the time.
• I have not really attempted to hit my macros every day, but I have been tracking my food.
• I have not really attempted to hit my macros, and I have not been tracking my food.

Are you currently tracking your food? If yes, please share your average daily calories and/or macronutrients from a typical week.

If you have this information and you feel that the information is reflective of a typical week for you, please share. This can have great influence over where we set your daily macro goals and take the guesswork out of finding a set that feels sustainable to adhere to.

Are you pregnant? *

• Yes
• No

Are you breastfeeding? *

• Yes
• No

Please share with us how many weeks postpartum you are, how often you’re expressing milk and your goals for breastfeeding as this will change your calorie and macronutrient needs.

Do you have dietary restrictions such as diagnosed food allergies? If yes, please list them here. *

Preferred meals per day? (1 to 8) *

Do you follow a particular dietary pattern? *

• Anything
• Mediterranean
• Paleo
• Vegetarian
• Plant Based

Do you suspect that you are undereating your calorie and macronutrient needs?

Please share with me why you believe your are undereating your calorie and macronutrient needs.

Do you prefer to eat higher carbohydrate containing foods or higher fat containing foods? If you’re not sure, list some foods that you tend to crave. *

Do you experience fluctuations in energy? Are there particular events or times in the day when you experience high or low energy? Please be specific in your description. *

Do you drink alcohol? If so, how many drinks per week do you enjoy? What type of alcohol do you prefer? Please be as descriptive as possible. You might be interested to know how alcohol impacts fat loss. Depending on your macro goals, you might have more or less room to play with alcohol. This is information is voluntary to share.

Is there anything else about you, your goals or your lifestyle that you think we should know? *

Submit