Client Application Form

Date of application form::

Salutation

--None-- Mr. Ms. Mrs. Dr. Miss

First Name

Last Name

Birthdate:

Age:

Gender:

--None-- Female Male

Phone:

Mobile

Email

Address

City

State/Province

Zip

Lead Source

--None-- TV ad Radio Ad Internet Ad Printed Ad 7 Secrets Book Seminar Google Search Facebook/Twitter Other Web Search Word of mouth Other Doctor Other Health Professionals

Friend or Health Care Prof Name:

Friend or Health Care Prof Phone + Email:

Present Weight (kg):

Height (cm):

Build:

--None-- Small Medium Large

Shoe size:

How many kilos would you like to lose?:

--None-- 1-6 kilos 7-12 kilos 13-18 kilos 19-30 kilos 30 - 50 kilos > 50 kilos

Do you do any exercise?:

--None-- Yes No

If so please list type and regularity::

Do you drink alcohol?:

--None-- Yes No

If so, how many glasses per week?:

Where are your worst problem areas?:
(Hold Control key for multiple fields)

Arms Breast Neck Waist Stomach Hips Bottom Thighs Calves

Do family members gain weight also?:

--None-- Yes No

Do you work night shifts?:

--None-- Yes No

Are you pregnant or breastfeeding?:

--None-- Yes No

Do you wish to become pregnant?:

--None-- Yes No

Have you been on IVF or intend to?:

--None-- Yes No

Are you peri, mid or post menopause?:

--None-- Peri (starting) Mid Post None

List any operations you have had::

Have you ever been diagnosed with cancer:

--None-- Yes No

If yes, please give cancer details::

Do you have type 2 diabetes?:

--None-- Yes No

Diabetes medication details::

Medical Conditions:
(Hold Control key for multiple fields)

Anaemia Bowel – give details below Candida Chronic Fatigue Coeliac disease Constipation Crohn’s disease Depression Diabetes (other than type 2) Dizziness Gall bladder problem Gall stones Hashimoto Heart – give details below Hepatitis High Blood pressure High blood sugar Irritable Bowl Syndrome Low blood pressure Low blood sugar Lupus Psoriasis Reflux Stomach staple/banding Thyroid – give details below Ulcerative colitis None Other – give details below

Details:

Other medical conditions / illnesses::

List all prescription medications used::

List all over the counter medications::

List all supplements and vitamins used::

Name of your regular doctor::

Doctor's phone number::

Indicate any allergies that apply to you:
(Hold Control key for multiple fields)

Dairy MSG Metabisulphite Shellfish Nuts None of these Other - please give details

Are you sensitive to wheat / gluten?:

--None-- Yes No

Are you lactose intolerant?:

--None-- Yes No

If so, which of these can you NOT eat?:
(Hold Control key for multiple fields)

Cheese Milk Yoghurt Other - please give details

Lactose intolerance details::

List any other foods you cannot eat::

Hospital admittance due to food or drug::

--None-- Yes No

Details of any food or drug reactivity::

Outline any other medical details::

Which program are you interested in?:

--None-- Essentials Program (20 weeks) Ultimate Program (1 year) Duo Program (for 2 people)

By submitting this form, I acknowledge that I have read and agree to the Terms and Conditions.