Questionnaire Form Step 1 of 9 11% Personal DetailsFirst Name* First Last Name* Last Email Address* GenderMaleFemaleAge18192021222324252627282930313233343536373839404142434445464748495050+ About Fitness & NutritionMy Fitness/Nutrition Goal is (check the top 3 most important goals) Lose Weight (Decrease body fat) Tone Muscles Increase Strength and Power Boost Energy Stress Less (Reduce Stress) Improve overall health and immune system My Level of workout knowledge is Above Average Average Below Average My level of nutrition knowledge is Above Average Average Below Average I can never have too many (check all that apply) Energy Boost or Pre-workout products Protein Products Detox Products Joint/Bone Health Products Muscle Building Products Labido Boosters Fat Burning Products Weight gaining Products Immune System or Anti-oxidant Products About Physical HealthWhat sport(s)/exercise do you participate in? None Football Rugby Cricket Rowing Athletics Running/Walking Tennis Boxing Squash Cycling/Biking Swimming Gym Other (Please Specify) OtherHow frequently do you participate in sports, exercise, or other activity?5+ days per week3 – 4 days per week1 – 2 days per weekOnce a monthLess than Once a monthHave you ever used any of the following types of sports nutrition product?CreatineProteinWeight GainerEnergy BoostFat BurnerEnduranceNutritionalNoWhy not?There’s too much choice I wouldn’t know where to startIt’s too expensiveI’m unsure of what’s in itNot sure it worksWhy did you use it?To help with the ache’s and pains afterwards.It’s important that I develop my game and keep up with the rest.I see the professionals use these sorts of products and want to see if they can help me as much as they help them.My coach has recommended me to use it.Did the product help you?Yes, I noticed an immediate difference in my performanceAfter using the product for 7 days I noticed a positive change in my performanceI think it more of a mental thing but I feel better having it straight after trainingI have not felt any difference since using the product About Body Type & DietBody TypeOverall, how satisfied are you with the physical appearance of your body?Please selectVery satisfiedSomewhat satisfiedSomewhat dissatisfiedVery dissatisfiedPersonal GoalsPlease selectNoneGain lean mass or gain weightDecrease body fatLose weightMaintain current body compositionFood ChoicesHow often do you eat?6 + times a day5-6 times a day3-4 times a dayStrictly Breakfast, Lunch, and DinnerLess than 2 times a dayBreakfast:YesNoSometimesHow many times a week do you eat breakfast?1234567Lunch:YesNoSometimesHow many times a week do you eat lunch?1234567Dinner:YesNoSometimesHow many times a week do you eat Dinner?1234567I eat at least three to five (3 to 5) servings of vegetables per day (a serving equals 1/2 cup cooked or 1 cup raw).AlwaysSome timesNot AlwaysI eat at least three servings (3) of fruit per day (a serving equals 1/2 cup fresh fruit or juice or 1/4 cup of dried fruit).AlwaysSome timesNot AlwaysI drink or get the equivalent of 3 cups (8 ounces) of milk per day (equivalent calcium 300 mg/cup through fortified fruit juice or dark green leafy vegetables).AlwaysSome timesNot AlwaysI limit my saturated fat (lard, butter, bacon, creams, etc.) intake.AlwaysSome timesNot AlwaysI eat in between six and ten servings of protein-based foods per day (1 ounce of meat, 1 egg or 3 egg whites, 1/4 cup tuna, 1-ounce cheese or 4-ounce tofu equals 1 serving).AlwaysSome timesNot AlwaysI drink at least eight cups (8 ounce per cup) of non-caffeinated fluid daily (water, juice, seltzer, etc.)?AlwaysSome timesNot AlwaysEating OutHow often do you eat out?Almost everydayA few times a weekLess than once a weekA few times a monthLess than once a monthRarely or NeverDigestion ProfileMy digestion/detox is fine the way it isI could use some digestion/detox help Immune ProfileDo you get more than three colds a year?YesNoDo you find it hard to fight off an infection (cold or otherwise)?YesNoHave you taken antibiotics in the past 3 years?YesNoDo you suffer from allergy problems?YesNo Glucose Tolerance ProfileDo you need more than 8 hours sleep a night?YesNoDo you find it difficult to wake up and get out of bed in the morning?YesNoDo you have tea, coffee, foods or drinks containing sugar, at regular intervals during the day?YesNoSometimesDo you often feel drowsy during the day?YesNoDo you get dizzy or irritable if you don’t eat often?YesNoDo you sweat a lot or get excessively thirsty?YesNoDo you sometimes lose concentration?YesNo Hormone ProfileHormone profile (females only)Do you experience any symptoms with menstruation (e.g. mood swings, pain)YesNoI could use an increased libidoYesNoHormone profile (males only)I could use an increased libidoYesNo PERSONAL STYLEWhat’s your level of Fitness/Nutrition/Supplement knowledge?Please selectNewbie: I’ll take all the help I can getSemi-proficient: I can handle the basicsDedicated enthusiast: I'm comfortable with nutritional informationAdvanced: I could teach a master classHow would you describe your Fitness / Nutrition / Supplement style?Please selectAdventurous: I’ll try any product onceClassic: I tend towards the traditionalTrendy: I'm the first to pick up new trendsLow-maintenance: I often keep things pretty naturalYou’ll always receive different types of products. But if you had to play favorites, you’d prefer:Please selectEnergy Boost/Pre-WorkoutsProtein Products (includes powders and foods)DetoxJoint/Bone HealthMuscle BuildersSexual HealthWeight Loss (Get Ripped)Weight GainersImmune/AntioxidantHow often would you like to receive Fitness / Nutrition / Supplement samples?Please selectAnytime!No more than 6 times per year MORE ABOUT YOUWhen is your birthday? How would you best describe your ethnicity?Please selectAsianBlack or African-AmericanWhite or CaucasianHispanic/LatinoSouth AsianOther race, ethnicity, or ancestryWhat is your household income?Please selectUnder $36,000$36,000 - $60,999$61,000 - $85,999$86,000 - $110,999$111,000 - $134,999$135,000 and upHow did you hear about RIPPEDience?Please selectAdvertisement - onlineAdvertisement - TVAdvertisement - podcast or radioA RIPPEDience Partner (Someone Invited Me)Friend / family member / coworkerGiven to me as a giftMagazine / news article - online or printInfluencer – I follow a (Youtuber, Blogger, Instagrammer, Celebrity) Personality on social media that was promoting youSearch (Google, Bing, Youtube)Social media (Facebook, Instagram, Twitter, Pinterest, Tumblr, SnapChat)Other1. Have you used or taken any vitamins, minerals, herbal products or other dietary supplements in the past year?If you are not sure what dietary supplements are, here are a few examples:YESNONOT SURE2. Do you consider taking vitamins or other supplements such as minerals and herbs to be essential for your health?YES, ESSENTIALNO, NOT ESSENTIALDON’T KNOW3. Has your doctor recommended that you take specific vitamins, minerals or other supplements for your health?PLEASE SELECTYESNODON'T KNOWWhich of these looks best describes the look you are interested in?MALEFEMALE FOR MALESkinnySkinnyfatTonedFitAthleticBuiltChubbyHeavyFOR FEMALESkinnySkinnyfatFitAthleticChubbyMuscularHeavyPowerlifterWhich of these brands do you love (or would love to try)?MHPFOCUSFURYEVLDETOURBPICELLUCORMPNOVEX BIOTECHGATNUTRABIOOTHEREnter Brand’s website if they have one here ContactTitle
