Name * First Name Last Name Email Address * Date * MM DD YYYY Rate yourself on the following: * I am complying well to my meal plan. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel confident I have things under control regarding my nutrition. Strongly Disagree Disagree Neutral Agree Strongly Agree This week, I binge ate due to stress or emotions. Strongly Disagree Disagree Neutral Agree Strongly Agree My meal plan is too difficult to follow. Strongly Disagree Disagree Neutral Agree Strongly Agree What came up for you in the past week that has impacted (either positively or negatively) your progress? * What is something you are proud of for this week? (Can be nutrition related or not) * What is something that you struggled with this week? * What do you think you need in order to succeed or continue to succeed in your goal? * The following fields are optional: Current Bodyweight (lbs) Current Body Fat % Measurement- Upper Arm Girth (cm) Measurement- Waist Girth (cm) Measurement- Hip Girth (cm) Measurement- Thigh Girth (cm) Thank you!
