Diet and lifestyle online form

Name: *

Date of birth: *

Phone number: *

Email *

Gender:

Female
Male

Any medical treatments? *

Any medicine in general? *

Your (What do you eat? How much do you eat (eg. big plate, small plate, 2 plates)) for Breakfast: *

Your (What do you eat? How much do you eat (eg. big plate, small plate, 2 plates)) for Lunch: *

Your (What do you eat? How much do you eat (eg. big plate, small plate, 2 plates)) for Supper: *

What is your general meal composition (eg: meat, bakery, fat meals, sweets, vegetables, etc.): *

How much water do you drink a day (ml): *

Anything more to drink? (eg. Cola or other type of liquid): *

What is that, how often and how much ml: *

During the main meals do you usually eat ? If yes, what? How often a day in general? (eg. chocholate, sweets, fruits, etc.): *

How often do you drink/take, and how much? Coffee, Cigarette, alcohol? *

Your job type: *

Office / Sedentary
Physical Worker / standing

Physical training (What do you do and how often): *

Any problem with your stomach or dignestion: *

Any problem with your heart or your vascular system: *

Any problem with your sugar and cholesterol levels: *

Do you have any allergy: *

If yes, for what and how often:

Please use the field below to leave any comments or information you think we should know!

What was the brand of your body composition machine? *

You not necessary need to provide this information, however to receive a well designed targeted advice, the numbers can be very useful to the dietitian. The advice can be more specific to aid your overall health! Please follow and fill in the sections below if you have your body composition result in hand. If you are one of our online Personal Training client and we work remotely you will need to provide this, otherwise your trainer will send your results to the dietitian.

Date of your measurement:

Height in cm:

Wight in KG:

BMI:

Body Fat %:

Total Body water (%):

Muscle Mass (kg):

Physique rating (1-9):

Bone mess:

Daily calorie intake (Kcal):

Basal Metabolic Rate (kJ):

Metabolic age:

Visceral Fat:

Name

Diet and lifestyle online form

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