Enter Your Name
Age
0-18
18-40
40+
Phone Number
Email
Height
Weight
Gender
CONTINUE
Do you currently exercise? If yes, how many days a week?
Yes, a bit
No, not really
How many meals per day do you eat?
What beverages do you drink?
Tea
Coffee
Water
Diet Soda
Do you drink alcohol?
Yes
NO
Do you smoke
Yes
NO
Do you want to lose or gain weight?
Loss of Weight
Gain of Weight
How often do you have chest pain
Never
Sometime
Regularly
List of all your Allergies
Did you had any prior operations
Describe any family history of eating disorders
Describe your current diet and what changes you want to make.
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