Please fill in your information

Your Name

Age Range
19 or under20-2930-3940-4950 and better

Height (specify FEET/IN/CM)

Weight (specify LBS/KG)

Mobile Number

Best Time to Reach You

Time Zone

Please fill in the questionnaire

1: What time do you typically wake up?

2: Who referred you to us?

3: What do you do for a living? (please specify shift work/desk work / manual labor)

4: What time do you typically eat breakfast and what it consists of?

5: When is your second meal and what does it consist of?

6: When is your third meal and what does it consist of?

7: List all the snacks you eat, everything that goes in your mouth:

Q.8: How much do you spend on groceries, coffee, snacks, meals on the go?

9: List the amount of cups you drink daily of coffee, soda, juice, alcohol, beer, wine:

10: How much water do you drink daily?

11: Do you take any supplements or vitamins? If yes what are you talking?

12: Are you consuming your daily recommended protein allowance?

13: Do you eat 5-7 servings of colourful fruits and vegetables daily?
YESNO

Explain

14: Do you eat wild fish at least 3 times a week? or supplement omega 3 fatty acids?
YESNO

Explain

15: Do you get 7-8 hours of sleep a night?
YESNO

Explain

16: Do you exercise a minimum 45 minutes 3-5 times a week?
YESNO

Explain

17: Are you at your ideal weight?
YESNO

Explain

18: Do you have problems with digestion, constipation, bloating?
YESNOMaybe / Sometimes

Explain

19: Do you sometimes have headaches, fatigue or other discomforts?

20: Do you have any other medical conditions? Joint Pain / Skin Problems / Heart / Diabetes?

21: Do you have any allergies?

22: What would you like to improve the most & why?

23: Is there anything that might get in your way to stop you from achieving your goal?

24: How serious are you from 1-10 to achieve these goals?