Name:
Age:
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Gender: Male Female
Email:
Telephone:
Height (cm):
Weight (kg)
Target Weight (kg)
Please outline your health goals:
Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roasts and other red meats?
- Yes No Unsure
Do you eat a variety of colourful fruits and vegetables and do you eat at least give servings a day of these?
- Yes No Unsure
Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?
- Yes No Unsure
Do you eat ocean-caught fish at least three times a week?
- Yes No Unsure
Do you avoid the intake of fried foods, dressings, sauces, gravies, butter and margarine?
- Yes No Unsure
Is your digestive system free of indigestion or irregularity?
- Yes No Unsure
Do you get a minimum of 30 minutes of exercise three to five days a week?
- - Yes No Unsure
Do you maintain a stable and appropriate weight?
- Yes No Unsure
Do you usually have time to prepare balanced meals rather than take-out or eating on the run?
- Yes No Unsure
Do you stay away from fizzy drinks and typical snack foods throughout the day and after diner?
- Yes No Unsure
Are you free of water retention and bloating?
- Yes No Unsure
Do you have the energy and focus you need to meet your daily challenges?
- Yes No Unsure
Do you drink at least eight glasses of water a day?
- Yes No Unsure
Are you getting your recommended daily allowance of Calcium? You should have a minimum of 800mg of calcium per day?
- Yes No Unsure
Please include any additional comments or questions you may have:
(If you have
none, just type 'None' in the box)
Finally, how did you find out about this website?
