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Dietitian Questionnaire
Please fill out this form so our licensed nutritionist can help customize your meals to match your needs.
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Name
*
Your answer
Email address
*
We use this email to reach out to you!
Your answer
Gender
*
Male
Female
Year of Birth
*
The year in which you were born
Your answer
Height (in centimeters)
*
Your answer
Weight (in kilograms)
*
Your answer
Physical Activity Level
*
Sedentary (office job)
Lightly active
Moderately active (2-3 work outs/week)
Active
Health problems
Diabetes, high blood pressure, high blood lipids etc.
Diabetes
Hypertension (high blood pressure)
Hyperlipidemia (high blood lipids)
Other:
Food allergies or intolerance
List your food allergies, intolerances and dislikes!
Celiac (or gluten intolerance)
Lactose intolerance
Tree nut allergy
Other:
Are you on any medication?
*
(If not, just type in "NO", otherwise, please provide a list of your current medications)
Your answer
Are you on a special diet?
Vegetarian
Vegan
Pescatarian
Paleo
No. I eat anything that moves. Or doesn't!
Other:
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Objective
*
Weight loss
Gain muscles
Increase energy level
Other:
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