NutriChoice4U
Client Questionnaire Form
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Email *
Contact Number *
Name *
Age *
Occupation *
City/Country *
Weight *
Height (Eg. 5 feet 7 inches ) *
Blood Group *
Total Meals Intake in a day ! *
Meal Preference *
Required
What food do you crave the most? ( tick all that are applicable to you ) *
Required
Do you feel like eating sweet dish post meals? *
How many hours do you sleep ? *
Do you feel fresh after waking up ? *
How Many Liters of Water Intake In a day ? *
How often do you perform any kind of Physical Activity in a week ?   *
Do you have any following illnesses? *
Required
What is your goal ? *
Required
Any past disease? if yes then please mention *
Anything important regarding your health which you would like us to know ? *
Any Medication taking daily or for pain ? *
Are you taking any kind of supplement? *
Do you experience any below issues regularly ? *
Required
Family History of any disease from below ? *
Required
Do you have any kind of allergies? ( if yes then please mention) *
Do you smoke ? *
Do you take Alcohol ? *
A copy of your responses will be emailed to the address you provided.
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