Do
you wake up feeling tired?
Yes
No
Do
you suffer from an energy loss during the day?
Yes
No
What
is Your Current Weight?
Kgs
What
is Your Goal Weight?
Kgs
What
is Your Height?
m
What
is Your Age?
Gender
Male
Female
What
weight-loss programs have you tried?
How
serious are you about losing weight?
What
is the particular reason you want to lose weight at this time?
How
many times a week do you eat out?
Do you exercise at the moment?
Yes
No
How much water do you drink per day?
Litres
Allergies : In the same way as you should not eat certain foods depending on your allergies please advise if you are allergic to any of the following:
Soya
Caffeine
Calcium
Any other Allergies
Thank you for your responses. Please use the space below for any other
information you think would help us to assist you with your weight
loss needs.
Optional
Information - On
an average day, what do you eat for: