Assessment Form

1
Date* This field is required.
Date
Month
Day
Year
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number
5
E-mail* This field is required.
example@example.com
6
Gender* This field is required.
Male
Female
7
Age?* This field is required.
8
Weight (lbs)measured as of this morning* This field is required.
9
Height (inches)* This field is required.
10
Goal weight (lbs)
11
How many times per week do you exercise?
12
For how long?
30 - 45 minutes
1.5 hours
1 hour
2 hours or more
Other
13
what exercises/activities do you engage in?
Walking
Cardio machines
Jogging
Strength training
Play Sport
Other
14
LIFESTYLE INFORMATION
15
What do you do for a living?
16
What is the activity level at your job?
None
Moderate
High
17
Does your job entail shift work?
Yes
No
18
If you follow a more regular schedule, when do you work?
Days
Afternoons
Nights
19
How often do you travel?
Rarely
Few times per week
Few times per month
Weekly
20
If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at leas 3x per week)?
Yes
No
21
If yes how long ago was it, and how long did it last?
22
If you have any diagnosed health problems, list the condition(s)
23
Do you have blood relatives who have had or has any of the following conditions
24
Do you have any of the following conditions?
25
Are you taking medication?* This field is required.
26
If yes please list medications
27
What additional therapies or interventions are being taken for the given health problem(s)?
28
If you have/had any injuries please list them
29
What additional therapies or interventions are being taken for the given injury(s)?
30
Do you smoke Tobacco?
31
If yes how often?
32
DIET HISTORY
33
Do you drink alcohol?
34
If yes how often?
35
List any food alergies that you have
36
List foods you like
37
List foods you dislike
38
List foods you would eat for one day at breakfast, lunch, dinner, supper and snacks (indicate the time you would eat each meal)
39
Are you on or have ever been on any special diet?
40
If yes please state
41
How often do you grocery shop?
42
How much money do you spend on groceries per month?
43
How many meals do you eat per day?
44
How many meals do you eat in restaurants or fast food places per week?
45
If you are currently using any nutritional supplements, please list them below, including doses
46
What change/s would you like to make?* This field is required.
47
Please indicate some topics or areas you would want me to focus on.
48
My Products
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My Bag
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My Bag
Great Product Name
$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Smoothie RecipePower Break moothie
$2.50Edit
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1
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10
Quantity
Meal PlanReceive your personalised meal plan designed based on your needs and input
$30.00Edit
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Total cost $0.00
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