Registration

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone *

Email *

Do you have a Personal Trainer? *

Yes
No
Not yet, but I want one assigned

Can we share the results and protocol with your trainer? *

Yes, that's fine
No, I rather you didn't

Personal Trainers information

First Name	Last Name	Email	Phone

Medical Questionnaire

Please complete the following questions to provide us a basic understanding of your goals and level of health prior to our initial consult.

In my opinion my level of health is *

a) Excellent
b) Good – rarely have any complaints
c) Needs improvement
d) Poor – have some major health issues

My diet is based on *

a) Whole foods, lots of fresh fruit and vegetables and eating sensibly
b) I’m on the run a lot so I eat out frequently
c) I eat donuts, take-out and drink coffee at least 2-3 times a week
d) I eat junk food regularly and very little fruits or vegetables

Health risks *

Check all that apply

a) I smoke or have smoked in the last year
b) I drink alcohol more than 1-2 drinks a week
c) Sweets and sugar are part of my daily diet
d) I am on prescription medication
e) I have taken or take non-prescription drugs
f) None
g) Other health risk

Other health risk *

I have been hospitalized or chronically ill at least once in my life *

Yes
No

Please explain your hospitalization and/or chronic illness further

I have allergies however mild *

Yes
No

What allergies do you have

I get shaky or nervous if I skip a meal *

Yes
No

I take supplements (vitamins, minerals, green juices, protein shakes) *

Yes
No

What supplements are you taking

I come in contact with chemicals on a regular basis (Pesticides, Insecticides, chemical cleaners etc.) *

Yes
No

Please list what you come in contact with regularly

List the other health issues

Any bad reactions to medications/vaccinations? *

Yes
No

Do you know which ones?

My energy level is *

a) Great I have plenty of get up and go
b) Good but some days are hard
c) Tired most of the time
d) Exhausted can barely function

I have someone in my immediate family with the following diseases *

a) Cancer
b) Heart Disease
c) Stroke
d) Addictions
e) Mental Disease
f) Diabetes
g) Other family disease

Other family diseases

My health has never been well since *

a) An injury
b) An illness
c) Stressful time in my life
e) Not Applicable

I take regular perscription medication *

Yes
No

Please list what medication you are taking

Is there anything else you feel is very important for us to know prior to the initial consultation?

Nutrition Customized Program *

Price: CAD$ 499.99 CAD

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Registration

Please fill out this registration form to start your Nutrition Customized program, for your better health! We will contact you within the next 24 hours with your initial consult and next steps.

Medical Questionnaire

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