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Lifestyle Questionnaire
Help us know how to tailor Divine Diets to meet your needs!

This intake evaluation form serves as your application. 30 applicants will be chosen for our 40% discounted one-month trial period beginning February 1, 2017. 5 people from that group will be offered FREE meals for that month in exchange for sharing their progress with future Divine Dieters!

Everyone who applies will receive 10% off their first year!
What is your First and Last name *
Your answer
What is your date of birth? *
MM
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DD
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What is your email address and phone number? *
Your answer
What are your health goals? *
Required
What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”. *
Your answer
What is your current weight, in pounds? *
Your answer
How many inches is your waist? *
Your answer
How many hours do you sleep each night? *
What medications are you currently taking?
Your answer
What is your gender *
Required
Do you smoke cigarettes? *
Do you use recreational drugs? *
How physically healthy are you?
How physically active are you? *
Required
Do you have existing medical conditions? *
Your answer
Do you have any dietary restrictions or preferences?
Your answer
Do you have any food allergies?
How many alcoholic beverages a week do you have? *
How much coffee do you drink a day? *
In a typical week, how often do you exercise? *
How often can you cook your meals a week? *
Required
How comfortable are you cooking your meals? *
Required
Are you currently working with a Doctor or other health practitioner for a medical condition?
If yes, does your doctor/practitioner know about your interest in Divine Diets? We like to work with medical advice to best suit your needs
Your answer
Are you interested in Ayurveda, or integrative medicine?
Do you know your Ayurvedic Type, or Dosha? *
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