Name *FirstLastYour addressEmail *Phone numberDate of birthFamily situationMarriedSingleOtherProfessionHeightWeightYour Body Weight One Year AgoAny medical issues? If yes, please describe your medical condition.If you are under medication, please report the medicine(s) that you are taking.Are you a smoker? Please, describe. Do you suffer from constipation?YesOn occasionNoFor women: Please, describe your menstrual cycleDescribe your physical activities Which meals do you regularly eat?BreakfastMorning snackLunchAfternoon snackDinnerWhat are your favorite snack foods?Do you eat or order from out?YesNoOn occasionHow often?5-7 times per week3-5 times per week1-3 times per weekOn occasionWhat kinds of cuisine?How many glasses of water are you having per day? How many cups of coffee are you having per day? How many alcohol beverages are you having per week? Other drinks?Do you like milk?YesNoNot a big funDo you like yogurt?YesNoNot a big funCheck the food groups that you DISLIKERed meatPoultryFish & seafoodLegumesCooked veggiesPotatoesRicePastaSaladsFruitsSweetsCheck the salads that you DISLIKELettuceCabbageCarrotTomatoCucumberBroccoliColi flowerBeet rootGreensHow many fruits do you have a day?On occasion1-2more than 3Other foods that you like to consumeOther foods that you try to avoid or dislike?CommentsPhoneSubmit
