Please fill out this form
Last Name
First Name
Your Email Address
Phone Number
Profession
Age
Height
Weight
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What are the biggest challenges you face in your health?
What is the ideal outcome you want to achieve?
What benefit would you get from achieving this outcome?*
On a scale of 0-10, how motivated are you to change your lifestyle and diet plan to achieve the desired outcome?
(
Min :
1
-
Max :
10
)
1
On a scale of 0-10, how confident are you now that you will change your lifestyle and diet plan to achieve the desired outcome?
(
Min :
1
-
Max :
10
)
1
Have you suffered significant emotional stress that could have contributed to the worsening of your symptoms?
Yes
No
Are you ready to follow the recommendations of the Metabolic Typing program regarding your new nutritional plan and supplementation specific to your unique metabolic type?
Yes
No
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Do you have or have you had people with serious illnesses in your family?
Do you take any medication? If yes, which ones?
Yes
No
Do you take supplements? If yes, which ones?
Are you allergic to shellfish, soy, wheat or any foods, substances, medications?
Do you smoke?
Yes
No
Do you drink coffee?
Yes
No
Do you drink alcohol?
Da
Nu
Do you have a weakness for certain foods?
Describe what your daily menu looks like.
What foods do you like the most?
How many times do you eat home-cooked food and how many times do you eat out, per week?
What oils and fats do you consume?
Use this space to write other important considerations about your health. The more specific your information is, the more I can help you.*
By submitting your data, you consent to the processing of personal data -
GDPR.
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