My Profile
Please fill-out this form to let us know a bit more about yourself. Be open, honest and provide as much information as possible
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Email *
Your Name *
In general, what are your goals? *
Check all that apply.
Required
Describe in more detail 2 topics you want to address during the consultation *
What is the problem you want to solve?
We can only discuss so much in a 45 minute session. Please choose a maximum of 2 topics and be specific with what exactly you want to address.
Goals *
What are you trying to achieve through this program? Take your time and be as specific as possible. Consider which areas in your life will improve with a better health. What are you long term-goals?
Challenges *
What are the challenges you are facing in relation to the goals you mentioned above?
Where are you struggling? (E.g Continuous hunger either true or psychological as food is a means of satisfaction, Hypoglycemic, Reduced endurance, Reduced appetite for new beginnings and taking initiatives , etc.).
Your age *
Your sex *
Your weight and height *
About you *
Write here about yourself. Let us know more about you. Provide as much info as possible (e.g marital status, number of kids and their age, who are you, what excites you and what not)
How would you like to change? *
How, specifically, would you like your habits, your health, your eating, and / or your body to be different
Health Status *
Do you have any health issues in the last months, or in general? Put as much detail as possible ( breaking nails, rashes , pains, indigestion, low energy, auto-immune issues etc)
The past *
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, what? Which of those things worked well for you, and why? Which things did not go so well?
Stress and recovery *
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:Given all the demands of your life, what is your typical stress level on an average day?
No stress
Extreme stress
Training / Fitness *
Describe what type of activities do you enjoying doing? Do you currently do some training?
How often do you train? *
How many times do you train in a week?
I don't train at all
Every day!
How is my typical day *
Describe in as much detail as possible what are your typical activites from when you wake-up until you sleep
Hobbies *
Add you hobbies. E.g In the past I was participating in local theatre play and would like to restart this at some point.
How easily do you commit? *
Are you usually good at committing and completing challenging tasks?
Describe what you ate yesterday? (or any typical day) *
Add timings for every meal, and the general nutritional preferences your have
Ready, Willing, and Able *
How READY, Willing , Able  are you to change your behaviours and habits
Not at all
Some what
Completely
Ready
Willing
Able
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