Client information form

First Name*

Last Name

Email Address*

Confirm Email Address*

Is there a specific reason for you booking this consult? (i.e. glucose regulation, sports performance, skin issues)*

Any current supplements (include dose and brand)*

How often do you take this supplement?*

Any known allergies*

Any current medications (include dose)*

What type of water fo you regularly consume*

Tap water

Bottled (plastic)

Filtered water (RO)

Filtered water (cartridge)

Average daily water consumption (in Litres)*

Do you drink coffee?*

Yes

If you selected Yes above, specify what type (i.e. caffienated), how much and how often in a week.*

Do you smoke?*

Yes

If you selected Yes above, how much and how often do you smoke a week?*

How often do you exercise and what type (i.e. running, resistance, calisthenics)*

On average, how many hours of sleep do you get per night?*

What is your diet on Monday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Tuesday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Wednesday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Thursday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Friday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Saturday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

What is your diet on Sunday? (Be as detailled as possible, if it is a home cooked meal include all ingredients i.e. spices)*

Do you work indoors or outdoors?*

Indoors

Outdoors

How many hours a week do you work?*

For initial consults, please fill out the client information form at least 2 days prior to your consultation time.