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First name
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Last name
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Email
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Phone
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Address
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City
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Zip / Postal code
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Date of Birth
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Day
Month
Month
Year
Gender
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Are you pregnant/breastfeeding?
Yes
No
Height (cm)
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Weight (Kg)
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Occupation
Please select the main reasons for your consultation.
Weight loss
Weight/muscle gain
Increase energy
Improve health
Other
If other, please specify.
Do you smoke cigarettes?
Yes
No
Do you drink alcohol?
Yes
No
If yes, how often do you drink?
1-3 nights per week
4-6 nights per week
Every night
If yes, how many standard drinks do you usually drink each time?
How often do you exercise?
Never
1-2 days per week
3-4 days per week
5+ days per week
Do you take any supplements? If yes, please list.
Do you have any digestive issues? If yes, please specify.
Do you suffer from any diseases or health conditions? If yes, please specify.
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Do you have any food allergies/intolerances?
Are there any foods/drinks that you do not eat? If yes, please list.
*
Please be aware that as a nutritionist I can help to improve your diet and lifestyle so that you look and feel better. I do not treat diseases. Please sign below if the information is true to the best of your knowledge.
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