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What is your birth date? ^*

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What are your short and long-term goals ___? ^*

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Do you take any medication? ^*

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Do you currently have any health problems? ^*

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What is your medical history? ^*

Any surgeries? Diseases?

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Have you done a blood test in the last 6 months? ^*

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No

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Do you have allergies or food intolerance? ^*

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What is your profession? ^*

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How do you get to work? ^*

Halfway there!

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What is the distance from home to work? ^*

In Km

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Do you engage in physical activity, and if so, how often and for how long? ^*

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On a working day, how many steps do you do on average? ^*

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On average, how many hours do you sleep every night? ^*

(In hours)

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Do you have restless sleep or difficulty falling asleep? If so, are you taking any medication? ^*

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Do you feel tired at any part of the day? ^*

Please explain in details when do you feel tired? Morning? Afternoon? Night? After meals? ect...

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Do you smoke? If so, how many cigarettes per day? ^*

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Do you experience pain? If so, where and how often? ^*

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Typically, how are your energy levels in everyday life? ^*

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Do you ever experience sudden drops in energy throughout the day? ^*

Yes

No

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Have you gained or lost more than 10 Kg in the past year? (Intentionally or unintentionally?) ^*

Please elaborate

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How many meals do you eat per day? How many snacks? ^*

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Have you ever been on a diet? If so, which one and why? ^*

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Are there any food groups that you don’t like, avoid, or are allergic to? ^*

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Do you take vitamins, minerals or dietary supplements (such as herbs/plants/food substitutes? If so, which ones and why? ^*

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What are your goals? How can i help you? ^*

Almost there :)
Give as much detail as possible, it will make our sessions more efficient :)

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Files

Use this section to upload any relevant document. (For example: Blood tests)
If you do not have anything to upload, skip by clicking "Next"

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Maximum file size: 10MB

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Please note any relevant information that was not covered above, or use this space for questions or concerns you might have. ^*

One step away from the end!

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Which of my packages are you interested in? ^*

For more details on my packages, please head to my website to make your selection: nutri-knight.com

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