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Medical History(select options that apply)
Acne/oily skin conditionsDizzinesskidney problem/fluid retentionAllergiesEczema/dry skin conditionsMenstrual problems/PMTArthritis/bone problemsEye irritationsPoor digestionAsthmaGastric problemsRespiratory problemsBladder problemsHair/scalp problemsSensitive teethBowel problemsHeadache/migraineSinus/hay feverBlood pressureHeart diseaseStressCancerHypoglycemia/blood sugarUlcersConstipationInflamed, sore gumsWounds/infection/skinDepressionInsomnia/sleep disordersProblems/slow healing yeastDiabetesIrritable bowel syndromeInfections/candida/thrush
List any other medical issues
List any medications you are currently taking
Are you interested in looking at different ways of making money?
DIET SPECIFIC QUESTIONS
About You (select options that apply)
I get 100% of the daily nutrition I needI take regular nutrition supplementation (vitamins/minerals/protein etc)I experience a loss of energy during the dayI exercise regularly?I take part in sports regularly?
Do any of the following apply to you? (select options that apply)
Crave fats/sugars/chocolate/junkfoodPoor appetite controlRe-gain weight loss easilyCellulite
Tell us about your diet (select options that apply)
My diet is high in junk foodMy diet is high in fatMy diet is high in sugarI use artificial sugar
How much water do you consume per day?
None1 glass2 glasses3 glasses4 glasses5 glasses6 glasses7 glasses8 glasses9 glasses10+ glasses
How much alcohol do you consume?
I don't drink alcohol1-5 drinks per week10-20 drinks per week20+ drinks per week
How often do you eat takeaways or eat out?
NeverOnce in a whileOnce a weekTwice a week3-4 times a week5-6 times a week7 times a week8+ times a week
Tell us about any diet programmes you have tried in the past and whether they worked
How much weight do you need to lose?
How much money can you have spare on a weekly basis for weight loss?
COSMETIC SPECIFIC QUESTIONS
Doe you use any of the following products?
CleanserTonerMoisturiserMasksMight CreamEye CreamExfoliantBody Creams/LotionsFragrances
List the cosmetic brands you regularly use
List any skin issues you have
Are you interested in receiving a complimentary facial?
Is there anything else you would like to tell us?