Nutrition Advice

Salutation*

First Name*

Last Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

What is your overall goal?*

Just choose 1.

What other improvements would you like to see?*

Choose as many as you like.

Lose weight/fat
Gain weight/Muscle
Minimise or get off medications
Change eating habits
Feel better/improve wellbeing
Improve Fitness
Improve sleep
Support other family members

Have you tried to lose weight before?*

Either by yourself or with professional help

Which diets have you tried before?

Check all that you have previously tried - with or without success.

Intermittent Fasting
Juicing
Ketogenic
Paleo
Vegan
Whole Foods Plant Based
Low Calorie
Low Fat
DASH

Describe your biggest challenge to reaching your goal.*

Give this some thought.

For you to feel that this program was successful for you, what would you need to gain from it?*

Not necessarily just weight related.

Are you currently on any medications prescribed by your doctor?*

Please list the name of the medication and what condition it has been prescribed for. If you are not on any prescribed medications please write "NIL".

Are you taking any non-prescription supplements?*

Please list any non-prescription medications or herbal supplements you are currently taking.

Comments

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YOU CAN BE HEALTHY AND HAPPY

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