Mission Jacked.com

Meal Plan Questionnaire

Complete The Meal Plan Questionnaire

Meal Plan Set Up

Please note that all fields followed by an asterisk must be filled in.

First Name*

E-Mail Address*

Country*

Sex*

Age*

Weight (lbs)*

Goal Weight (lbs)

Height (ft)*

Health Issues?*

Medications

Activity Level*

	Slightly Active
	Moderately Active
	Very Active

Goal*

	Lose Fat
	Lose Fat & Build Muscle
	Build Muscle

Food Allergies*

Are You Using Any of The Following Diets

	Ketogenic Diet
	Carnivore Diet
	Intermittent Fasting
	Low-carbohydrate Diet
	Paleolithic Diet
	Vegetarianism
	Mediterranean Diet
	Other
	Gluten-free Diet.

Proteins You Don't Like

	Chicken
	Beef
	Eggs
	Beef Liver
	Cottage Cheese
	Shrimp
	Salmon
	Mackerel
	Protein Powder
	Cod
	Yogurt

Carbs You Don't Eat

	White Rice
	Honey
	Brown Rice
	Yams
	Sweet Potatoes
	Rice Cakes
	Quinoa
	White Potatoes
	Pita Bread
	Wild Rice
	Pasta

Fats You Don't Like

	Olive Oil
	Avocardoes
	Cheese
	Macadamia Oil
	Chi Seeds
	Avocado Oil
	Butter

Nuts You Don't Like

	Walnuts
	Macadamia Nuts
	Almonds

Fruit You Don't Like

	Blueberries
	Strawberries
	Orange
	kewi
	Bananas

Vegetables You Don't Like

	Green Beans
	Broccoli
	Leavy Greens
	Leeks
	Cabbage
	Peppers
	Cucumber
	Green Salad
	Pickles

Do You Eat Breakfast

	Yes
	No

Do You Have A Set Meal Time?

	Yes
	No

What do You Eat In One Day?

Favorite Snacks or Junk Foods*

Daily Soda Intake*

Daily/Weekly Alcohol Intake*

Do You Use Protein Powders*

	Yes
	No

How Much Protein Do You Consume Per Day?*

	Below 50g
	50g & 75g
	75g & 100g
	100g & 125g
	125g & 150g
	150g & 175g
	175g & 200g
	200g & 225g
	225g & 250g
	More Than 250g

How Many Calories Do You Consume Per Day?*

How Much Sleep Do You Get Per Night?

	Less than 5 hours
	5-6 hours
	6-7 hours
	7-8 hours
	More than 8 hours

How Much Water Do You Drink?

How Many Daily Steps Do You Do?

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Mission Jacked L.L.C

Address: 9407 NE Vancouver Mall Dr

STE 104 #1269

Vancouver, WA 98662 USA

Office Hours: 9am-5pm Mon-Fri (PST)

Tel: 509 608 1046

Email: mission@missionjacked.com

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