Name: *

Age:

Gender:

Email: *

Telephone: *

Height (cm):

Weight (kg)

Target Weight (kg)

Please outline your health goals:

Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roasts and other red meats?

Do you eat a variety of colourful fruits and vegetables and do you eat at least five servings a day of these?

Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?

Do you eat ocean-caught fish at least three times a week?

Do you avoid the intake of fried foods, dressings, sauces, gravies, butter and margarine?

Is your digestive system free of indigestion or irregularity?

Do you get a minimum of 30 minutes of exercise three to five days a week?

Do you maintain a stable and appropriate weight?

Do you usually have time to prepare balanced meals rather than take-out or eating on the run?

Do you stay away from fizzy drinks and typical snack foods throughout the day and after dinner?

Are you free of water retention and bloating?

Do you have the energy and focus you need to meet your daily challenges?

Do you drink at least eight glasses of water a day?

Are you getting your recommended daily allowance of Calcium? You should have a minimum of 800mg of calcium per day?

Please include any additional comments or questions you may have:

(If you have none, just type 'None' in the box)

Finally, how did you find out about this website?