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Athletic Loss Plan
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Name
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Email
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Age
*
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Address
*
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Phone number
Your answer
Current Weight (KG)
Your answer
Desired Body Weight (KG)
Your answer
Reasons why you want to go on diet
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What are your nutrition goals?
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Do you have any preference in food diet?
Yes
No
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Have you followed any diet trend?
Yes
No
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Was the diet trend you followed effective?
Yes
No
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Please share the diet trend you followed and the effectiveness here.
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Do you have any eating disorder ?
Yes
NO
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If yes, please share it here so that we are aware about it.
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Do you have any allergies ? if yes, please list them below:
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Are you currently taking any medications?If yes,please list them below:
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Please check below if you have any of the current health conditions:
Gastrointestinal
Respiratory
Cardiovascular
Neurological
Dermatological
Musculoskeletal
Urinary
Reproductive
Metabolic
Endocrine
Cancer
Are you smoking?
Yes
No
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Are you drinking alcohol?
Option 1
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Are you vegetarian?
Yes
No
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Do you go to the gym?
Yes
No
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