Health and nutritional questionnaire

Please complete the online form below to receive a quotation for an Eating Plan via e-mail:

All information submitted is kept CONFIDENTIAL

Name and surname Tel / Cell Email Preferred  Language   Afrikaans  English     Sex Male Female Age years Weight (kg) kg Height (cm) cm Waist (cm) cm Hips (cm) cm Do you smoke? -- please select -- No, I don't smoke less than 5 per day 5 - 10 per day 10 - 20 per day 20 - 30 per day more than 30 per day Do you Exercise? -- please select -- No, I don't exercise 1 time per week 2 times per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week Type of exercise? -- please select -- Weights Cardio Walk the dog How much alcohol do you consume? -- please select -- None Little Moderate High Excessive Please list any cronic illnesses, if any Which of the following blood values are elevated? None Total Cholesterol LDL Cholesterol Triglycerides Fasting Glucose Insulin Uric Acid Do you suffer from any of the following? Stomach cramps Constipation Diarrhoea Reflux Heartburn Excess Gas Food Intolerance Food Allergies Any other? Have you been on any slimming Diets? Yes No Is your weight fluctuating? Yes No List current medication List current supplements Do you cook with Butter Oil Margarine What do you usually have for breakfast? What do you usually have for Lunch? What do you usually have for Dinner? What do you snack on?   Morning Afternoon Late Night Do you binge eat? Yes No How often? How much of the following do you consume?   Per Day Per Week Milk Fat Free Full Cream 2% Fat Yoghurt Fat Free Low Fat Fruit Fresh Dehydrated Canned Juice Vegetables Cooked Raw Bread White Brown Seed or Whole Grain     Other Comments

Please enter the text you see above: