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Name
Contact
Email
Age
18
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59
60
61
62
63
64
65+
Gender
Male
Female
Other
Current Weight
Your desired body weight.
How often do you work out?
a. No, I don’t work out
b. 1-2 times a week
c. 2-5 times a week
d. More than 5 times
How tired do you typically feel during the day?
a. I feel tried before the meal.
b. I feel tried in the afternoon.
c. I feel tired in the evening.
d. I am a ball of fire all day
Select all the that you tend to do
a. I eat late at night
b. I love soft drinks
c. I consume hard drinks (Alcohol) often
d. I have fatty and salty food
How much do you usually sleep?
a. Less than 5 hours
b. 5-6 hours
c. 7-8 hours
d. More than 8 hours
How much water do you drink daily?
a. Only coffee and tea
b. Less than 0.5-1.5L (2-6 glasses)
c. 1.5 -2.5L (7-10 glasses)
d. Don’t count, it depends
Why you want to lose weight?
a. Special occasion
b. Health reasons
c. Others ___
Do you have any additional health concerns or conditions? (Allergy message)
Submit
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Name
Contact
Email
Age
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+
Gender
Male
Female
Other
Weight
Do you have diabetes?
Yes
NO
Do you Smoke?
Regular
Once a week
Often
I Don't
Do you drink?
Regular
Once a week
Often
I Don't
What is your sodium level?
Normal
High
Moderate
What is your potassium level?
Normal
High
Moderate
What is your Phosphorus level?
Normal
High
Moderate
Do you have muscle weakness?
Yes
No
Do you feel numbness in your arms and legs?
No
Yes Sometimes
Very Frequent
Do you have frequent chest pain?
No
Yes Sometimes
Very Frequent
Do you have any additional health concerns or conditions? (Allergy message)
Submit
