About this template
A short challenge still needs a signup that is more than a name. This registration collects contact details, who referred them, and that person's name if there is one. They check the areas they want to improve, write why they are joining, and say whether they have a medical condition they want you to know about, with room for details. A second question asks if they are already on a nutrition program.
The habit section is specific because the source was specific: weekly sodas, chips, chocolate, peanuts, alcohol, juice, junk-food orders, and restaurant orders, then daily water, coffee, and tea. Meals run from breakfast through a bedtime snack. A last paragraph covers a habits grid the source stored as a matrix. A mobile-widget field from the source is left off. It was not a question.
This signs someone up. It does not diagnose, prescribe, or promise a result. If you are a coach, read the medical note and send people to a clinician when the answer is outside what you are qualified to handle. The three-day trial in the original title is just the program length. Change the title if yours runs longer.
Key features
- Signup plus a referral name, not only an email address.
- Goals are checkboxes: weight, energy, eating, sleep, and stress.
- Medical conditions and an existing nutrition program are yes-or-no, with details.
- Habit counts cover drinks, snacks, and a simple meal recall.
- Does not claim a health outcome. It only registers the person.
Use cases
- A gym or coach opening a short weight-loss challenge.
- A clinic collecting habits before a group program.
- A workplace wellness signup.
- A trial week where you need a baseline of drinks and meals.
What this form collects
- Full Name (Short answer)Short answer.
- Contact Number (Short answer)Include a country code if you are not in the same country.
- Referral Source (Dropdown)Pick the closest match.
- Referring Friend Name (Short answer)Short answer.
- Goal Improvement Areas (Checkboxes)Select every option that applies.
- Motivation Statement (Paragraph)A sentence or two is enough.
- Medical Conditions Status (Multiple choice)Pick the closest match.
- Medical Conditions Details (Paragraph)A sentence or two is enough.
- Nutrition Program Status (Multiple choice)Pick the closest match.
- Nutrition Program Other Details (Paragraph)A sentence or two is enough.
- Sodas Intake (per week) (Short answer)A number or short range is enough.
- Chips Intake (per week) (Short answer)A number or short range is enough.
- Chocolates Intake (per week) (Short answer)A number or short range is enough.
- Peanuts Intake (per week) (Short answer)A number or short range is enough.
- Alcohol Intake (glasses) (Short answer)A number or short range is enough.
- Fruit Juice Intake (glasses) (Short answer)A number or short range is enough.
- Junk Food Orders (Short answer)Short answer.
- Restaurant Orders (Short answer)Short answer.
- Water Intake (glasses/day) (Short answer)A number or short range is enough.
- Coffee & Tea Intake (glasses/day) (Short answer)A number or short range is enough.
- Breakfast (Paragraph)A sentence or two is enough.
- Morning Snack (Paragraph)A sentence or two is enough.
- Lunch (Paragraph)A sentence or two is enough.
- Afternoon Snack (Paragraph)A sentence or two is enough.
- Dinner (Paragraph)A sentence or two is enough.
- Bedtime Snack (Paragraph)A sentence or two is enough.
- Healthy Habits Frequency Matrix (Paragraph)One line per item: the code or habit, then the value.
FAQ
Is this medical advice?
No. It is a registration and a habit snapshot. People with a condition that needs a clinician should get that care separately.
Why so many food counts?
They came from the source form: sodas, chips, chocolate, peanuts, alcohol, juice, takeaway, and meals. Delete the ones you will not use.
What is the habits matrix?
The source had a grid. Here it is a paragraph: one habit per line, then how often. You can rebuild a grid in the Forms editor if you want one.
Can I drop the three-day limit?
Yes. Rename the form. The questions do not assume the challenge lasts three days.
Do I have to require the medical question?
The status question is required so you are not guessing about a blank. The details box is optional.
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