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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
What is your date of birth?
What is your email address and phone number?
What are your health goals?
Sports or Athletic training
Allergen Sensitive diet
What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.
What is your current weight, in pounds?
How many inches is your waist?
How many hours do you sleep each night?
4 or fewer hours
9 or more hours
What medications are you currently taking?
What is your gender
Do you smoke cigarettes?
Do you use recreational drugs?
How physically healthy are you?
Not so healthy
Not at all healthy
How physically active are you?
I work out, or do high energy sports or activities most days
I do light to moderate activity (yoga, walking, etc) at least 30 minutes a day
I try to get at least an hour of movement in 3 times a week
I'm on my feet all day for work, such as a waitress, nurse, surveyor etc
I walk my family dog
I am mostly sedentary
Do you have existing medical conditions?
Do you have any dietary restrictions or preferences?
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?
I don't regularly exercise
once a week
2-4 times a week
5-7 times a week
How often can you cook your meals a week?
I don't have time to cook (even if I wanted to!)
Only on the weekends
Dinners, most nights
Once a week
3 times a week
How comfortable are you cooking your meals?
Give me a recipe, and I do great!
I need careful instructions
I'm happy to cook if it takes less than 30 min
I need to learn the basics
Are you hiring? :)
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
Are you interested in Ayurveda, or integrative medicine?
I am an avid follower of Ayurveda
I am interested in Holistic Medicine
I am interested in Integrative Medicine
I am an Ayurvedic/Integrative Medicine Health Pracitioner
Do you know your Ayurvedic Type, or Dosha?
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