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Medical History & Nutrition Related Questions
Please indicate whether you have been diagnosed with or have experienced any of the following:
Anxiety or Chronic Panic Attacks
Arthritis (osteoarthritis or rheumatoid)
Chronic Fatigue Syndrome
Diabetes Type 1
Diabetes Type 2
High Blood Fats (cholesterol/triglycerides)
High Blood Pressure
If applicable, please provide any further conditions you have that were not mentioned above:
Do you have any allergies and/or food intolerances? If yes, please indicate below
Do you currently take any supplements or vitamins? If yes, please indicate below
What is your main goal of working with a dietitian? (Example: Learn to eat with diabetes, or lose excess weight, etc.)
Would you be willing to work toward adopting a new lifestyle? This includes potential changes to your current diet and exercise routines?
How active are you?
sedentary (1-2 hours a week)
moderately active (3-5 hours a week)
active (6-7 hours a week)
athlete (8 hours or more a week)
Terms & Conditions
Health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.
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