Email Address

Gender Gender *malefemaleother

Package What package are you interested in? *Speed Date PackageEngage PackageConsultation Package

Are you pregnant or post partum (less than 6 weeks)? Are you pregnant or post partum (less than 6 weeks)? yes no

Name

Weight in kg

Has your doctor ever told you that you have a heart condition or cardiovascular condition or have you ever suffered a stroke? Has your doctor ever told you that you have a heart condition or cardiovascular condition or have you ever suffered a stroke? yes no

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Height in cm

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? yes no

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? yes no

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If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? yes no

Please provide details

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Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? yes no

Please provide details

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exerciseng your blood glucose in the last 3 months? Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exerciseng your blood glucose in the last 3 months? yes no

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Have you ever been advised by a doctor, physician or specialist not to perform any specific type of exercise/activity? Have you ever been advised by a doctor, physician or specialist not to perform any specific type of exercise/activity? yes no

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Has your doctor ever told you that any of the following biomarkers were too high or too low: Has your doctor ever told you that any of the following biomarkers were too high or too low: blood pressure blood sugar blood lipids / cholesterol

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Are you taking any prescribed medications? Are you taking any prescribed medications? yes no

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Are you taking any dietary supplements? Are you taking any dietary supplements? yes no

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Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned? Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned? yes no

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Do you adhere to any of the following diets? Do you adhere to any of the following diets? Keto Vegetarian Vegan Atkins-type Other

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Do you practice any type of time restricted eating (intermittent fasting, alternate day fasting, etc.)? Do you practice any type of time restricted eating (intermittent fasting, alternate day fasting, etc.)? yes no

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What are your diet preferences and constraints (intolerances and/or allergies)?

What are your current exercise habits? Please describe frequency, duration, intensity, and type.

What are your exercise preferences and constraints?

Is there anything else you would like me to consider Is there anything else you would like me to consider yes no

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