PROGRAM QUESTIONNAIRE

Welcome to the Mothership.

Take your time with this. The more detail you give, the better the program we build together.

ABOUT YOU

Full Name *

Email *

Phone

Date of Birth

Age

Are you based in Miami?

What piece of content motivated you to join The Mothership?

Instagram Handle

BODY STATS

Height

e.g. 5'3"

Current Weight (lbs)

Body Fat % (if known)

You can get this from a DEXA scan, InBody, or smart scale.

Lean Mass (lbs, if known)

Body Composition Notes

Paste results from DEXA, InBody, or smart scale if you have them.

Body Type

Are you open to entering your body weight daily in the app?

Ideal Weight Goal (lbs)

At what age/weight were you HEAVIEST?

At what age/weight were you LOWEST?

How often do you weigh yourself? Is it an emotional trigger?

GOALS

What are your body goals?

Do you have a hard time gaining muscle?

Are you looking to reduce body fat?

Do you want medium, fast, or the fastest results?

What would you like to gain from your experience with Mothership Wellness?

HEALTH & MEDICAL

Do you have any injuries, medical conditions, or limitations?

Please list any prescribed medications or supplements you take regularly

Are you taking any GLP-1 medication (Ozempic, Wegovy, etc.)?

Are you currently breastfeeding?

Menstrual Cycle (if applicable)

When does your cycle usually start?

Have you ever had therapy? If yes, describe briefly.

Do you struggle with any of the following?

NUTRITION

Activity Level

Used to calculate your calorie and macro targets.

Sedentary: Little to no regular exercise

Mild: Light exercise 1-3x/week

Moderate: Exercise 30-60 min, 3-4x/week

Heavy: Intense exercise 60+ min, 5-7x/week or physical job

Extreme: Multiple daily training sessions or very demanding physical job

Primary nutrition concerns (select all that apply)

Food or supplement allergies

Food sensitivities or prefer to exclude from meal plan

Do you currently follow a specific diet?

Any dietary preferences?

Who do you live with? Who makes your meals? Cook at home or eat out mostly?

Willingness to cook (1-10, 10 = very willing)

Grocery stores and restaurants you use

Do you consume most (80%+) of your foods as unprocessed whole foods?

Do you consume non-starchy veggies with each meal?

Have you ever worked with a dietician or nutritionist?

Estimated daily calorie intake right now

What do you consider your biggest nutritional problem?

Preferred meals per day

How many meals per week do you dine out?

Daily coffee (8 oz cups)

Daily water (8 oz cups)

Alcoholic drinks per week

Hours sitting at a desk per day

TRAINING

Current workout level

How many cardio sessions per week can you commit to?

How many strength sessions per week can you commit to?

Which days are you available to workout?

Preferred workout time of day

Realistic session duration (minutes)

Gym, home, or either?

List all home equipment available

Describe your current exercise routine

Do you know what Progressive Overload is?

If you purchased 1:1 personal training, what days/times are preferred?

WORK & LIFESTYLE

Briefly describe your work or school conditions

Do you travel for work?

What systems do you use to stay organized?

What is your biggest STRUGGLE right now?

What is your biggest JOY right now?

COMMUNITY

May Ashley feature you on Instagram stories?

Are you aware of the referral program?

Anything else you would like Ashley to know?

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