Please enable JavaScript in your browser to complete this form.Name *FirstLastYour addressEmail *Phone numberDate of birthFamily situationMarriedSingleProfessionHeightWeightYour 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?YesNoOn occasionFor women: Please, describe your menstrual cycleDescribe your physical activities How often do you have breakfastEvery dayOftenOn occasionNeverWhat are you usually having for breakfast?Can you please tell us which meals you are usually having?What are you usually having for snack?Are you an excessive salt consumer?YesNoOn occasionHow 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? Do you drink milk? YesNo, but I couldNo, I don't like milkDo you like yogurt? YesNo, but I couldNo, I don't like milkDo you like feta cheese?YesNo, but I couldNo, I don't like milkCheck the food groups that you DISLIKERed meatPoultryFish & seafoodLegumesCooked veggiesPotatoesRicePastaSaladsFruitsSweetsCheck the salads that you DISLIKELettuceCabbageCarrotTomatoCucumberBroccoliColi flowerBeet rootGreensHow many fruits do you have per day?1234moreOther foods that you like to consumeOther foods that you DISLIKECommentsCommentSubmit
