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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.
Name
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Required
First
Last
Address
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Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
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Congo, Republic of the
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Gambia
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Ghana
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Guinea-Bissau
Guyana
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Hungary
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Indonesia
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Iraq
Ireland
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Liberia
Libya
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Madagascar
Malawi
Malaysia
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Mali
Malta
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Mauritania
Mauritius
Mexico
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Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
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Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
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Saint Lucia
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Samoa
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Serbia
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Sint Maarten
Slovakia
Slovenia
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Sudan, South
Suriname
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Sweden
Switzerland
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Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
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Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
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Uzbekistan
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Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Phone
*
Required
Email
*
Required
Do you have a Personal Trainer?
*
Required
Yes
No
Not yet, but I want one assigned
Can we share the results and protocol with your trainer?
*
Required
Yes, that's fine
No, I rather you didn't
Personal Trainers information
First Name
Last Name
Email
Phone
Add or remove row
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.
My Current goal is to
*
Required
a) Lose weight
b) Tone my muscles and get back into shape
c) Serious body building
d) Extreme sports/Marathon
e) Gain weight and build muscle tone
f) Get healthy
Other
In my opinion my level of health is
*
Required
a) Excellent
b) Good – rarely have any complaints
c) Needs improvement
d) Poor – have some major health issues
My diet is based on
*
Required
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
*
Required
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
*
Required
I have been hospitalized or chronically ill at least once in my life
*
Required
Yes
No
Please explain your hospitalization and/or chronic illness further
I have allergies however mild
*
Required
Yes
No
What allergies do you have
I get shaky or nervous if I skip a meal
*
Required
Yes
No
I take supplements (vitamins, minerals, green juices, protein shakes)
*
Required
Yes
No
What supplements are you taking
I come in contact with chemicals on a regular basis (Pesticides, Insecticides, chemical cleaners etc.)
*
Required
Yes
No
Please list what you come in contact with regularly
Health issues that apply to you (past or present)
*
Required
a) Headaches
b) High or Low Blood Pressure
c) Hypoglycemia (Low Blood sugar)
d) Diabetes or blood sugar problems
e) Premature ageing/greying hair
f) Hair loss
g) Joint pains
h) Hormone imbalances
i) Tumour growths
j) Insomnia
k) Allergies
l) Dental problems/bleeding gums
m) Bone loss (osteoporosis)
n) Kidney and/or Liver problems
o) Heart Conditions
p) Digestive Disturbances
q) Thyroid problems
r) Impaired healing or easy bruising
s) Difficulty concentrating/poor memory
t) Difficulty dealing with stress
u) Skin problems (such as acne)
v) Emotional issues
w) Chronic infections
x) Other health issues
List the other health issues
Any bad reactions to medications/vaccinations?
*
Required
Yes
No
Do you know which ones?
My energy level is
*
Required
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
*
Required
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
*
Required
a) An injury
b) An illness
c) Stressful time in my life
e) Not Applicable
I take regular perscription medication
*
Required
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
*
Required
Price:
CAD$ 499.99 CAD
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