First Name *

Last Name *

Email *

Gender *

• Male
• Female
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How did you find us? *

e.g. found your social media page, a conversation via DMs, through a friend etc.

What is your body weight in kg? *

What do you do for a living?: *

What level of physical activity does your job require?: *

None

Moderate

High

Does your job involve shift work?: *

Yes

No

If yes, can you explain your shift patterns:

If you follow a more regular schedule, do you work mornings, days or nights?: *

Mornings

Days

Nights

What would you like to achieve over the next 6 months, if we were to work together? *

On a scale of 1-10, how much of a priority is your goal? *

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
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10 being your fully willing to make your goal(s) a top priority

What do you think is holding you back from achieving your goals? *

How long have you been trying to achieve this goal? *

Less than 6 months

1-2 years

3-5 years

All my life

Have you been diagnosed with, experienced, or undergone any of the following (please tick all symptoms that apply):

Anemia

Anxiety / depression

Carpal tunnel syndrome

Diabetes type 1

Endometriosis

Graves disease

Hiatus hernia

IBS

Polycystic ovary syndrome (PCOS)

Seizures

Anorexia

Breast implants

Chronic fatigue

Diabetes type 2

Gall bladder removal

Hashimotos

Other thyroid conditions

IBD

Root canal(s)

Ulcers (stomach)

Others

Upper gastrointestinal system (please tick all symptoms that apply):

Belching after eating

Heartburn or acid reflux

Feel better if you skip meals

Brittle hair / hair loss

Undigested food in stool

Lack of desire to eat meat

Bad breath

Rosacea

Persistent cough

Bloating in the stomach region

Feel excessively heavy after eating meat

Fragile fingernails

Diarrhoea after eating

Frequent use of PPI's or antacids

Discomfort when swallowing tablets

Frequent hiccups

Indigestion

Esophageal / diaphragm spasms

Small intestine / microbiome (please tick all symptoms that apply):

Bloating after eating (around belly button region)

Hay fever, congested sinuses or seasonal rashes

Constipation

History of UTI's

Nerve pain

Brittle hair / fingernails

Poor exercise tolerance (e.g. bad muscle soreness)

Food allergies / sensitivities

Diarrhoea or loose stools

History of food poisoning or traveler's bug (even if one off)

Dry eyes or mouth

Pins and needles or sleeping limbs

Poor facial skin tone (e.g. look washed out)

Joint pain / neck stiffness / knee pain / finger pain

Large intestines (please tick all symptoms that apply):

Coating on your tongue

Itchy inner ears

Taken more than 5 courses of antibiotics in your life

Jock itch, dermatitis or fungal rashes

Excessively bad smelly gas

Born via caesarean section

Itchy scalp / dandruff

Overly sensitive to alcohol

Blood in stool

Bloating lower down (below belly button)

Anus or vaginal itching

History of fungal or yeast infections (including athletes foot)

Flakey skin on bottom of feet / heels

Frequent passing of gas

Stomach cramps

Anxiety or low motivation

Lethargy / fatigue

Sugar cravings

Have you ever been tested for Helicobacter (H. Pylori). If yes, was the result positive or negative? *

Yes

No

If positive, what therapy / treatment, if any, did you undergo?

Liver and gallbladder (please tick all symptoms that apply):

Pain between shoulder blades

Stomach upset by fatty foods

Loose stools or oily substance in toilet water

Motion sickness

Get easily hungover if you drink alcohol

Sensitive to chemicals / perfumes

Chronic fatigue or lethargy

Gall bladder removed

General itchiness / itchy palms

Feel full for an extended period of time after eating fats

Feel sluggish after consuming fats

Adrenal function (please tick all symptoms that apply):

Difficulty falling asleep

Difficulty waking up or getting going in the morning

History of high or low blood pressure

Grinding teeth at night

Chronic back or knee pain

Become dizzy when standing suddenly

Crave salty foods

Emotionally traumatic events in the past

Thyroid function (please tick all symptoms that apply):

Easily fatigued or sleep during the day

Difficulty waking up or getting going in the morning

Sensitive to cold temperatures

Constipation

Hair loss or thinning of eyebrows

Poor short term memory

Consistently low mood

Currently on the birth control pill

Don't use a fluoride water filter for drinking

History of Epstein Barr virus

Blood sugar (please tick all symptoms that apply):

Awaken during the night

Crave sweet foods

History of binge eating

Irritable if going long periods between meals

Frequent thirst or urination

Headaches or blurred vision between meals

Shaky between meals

Eating relieves fatigue

Eating causes fatigue

History of diabetes in the family

Restless leg syndrome

Women's health (women only - please tick all symptoms that apply):

PMS

Crave chocolate around periods

Heavy or painful menstrual flow

Skipped periods

Variation of menstrual cycle length

Painful intercourse

Store most of your body fat around your hips or glutes

Excessive facial or body hair

Hot flushes or night sweats

Acne

History of taking birth control pill

Nickel allergy (including earrings)

Please list any more information regarding your female health if applicable. For example - type of birth control, conditions present such as PCOS etc.

Dental health (please tick all symptoms that apply):

Have any veneers

Have plaque build up

Gums bleed when brushing

Suffer with gingivitis

Wear braces

Have sensitive teeth

Have one or more root canals

Have fillings

Never floss

Floss often

Not using fluoride free toothpaste

Please list any more information regarding your dental health if needed. For example - total number of fillings, root canals, history etc.

Serotonin (please tick all symptoms that apply):

Depression

Anxiety

Seasonal depression

Difficulty falling asleep

Highly sensitive to pain

Prone to obsessive behaviours

Loss of enjoyment of hobbies

Social phobias

Dopamine (please tick all symptoms that apply):

Depression

Poor concentration or focus

Poor balance

Low energy

Sleep too much

Tendency towards addictive behaviours

GABA (please tick all symptoms that apply):

Anxiety

Insomnia

Panic attacks

Muscle tightness

Use food, alcohol or tobacco to calm down

Do you currently take any prescription medication? If so, what type, why, what dosages, and how long have you taken it for? (this includes any contraceptive medication). *

If not, please write "none".

Do you have any dietary restrictions for example vegetarian or vegan? *

Please list all the foods you eat on a daily basis: *

Known food sensitivities or triggers? *

Are there any foods you dislike?: *

Please list what supplements you currently take: *

What is your average daily calorie consumption?: *

What is your average daily total protein Intake?: *

What is your average daily total fat Intake?: *

What is your average daily total carbohydrate Intake?: *

Do you frequently consume vegetables in at least 2 of your meals a day?: *

Yes

No

If you were to skip a meal, how do you feel? Mark all that apply: *

Fine

Restless

Mood swings

Tired

Agitated

Angry

Have you currently got any injuries?: *

Have you previously broken any bones?: *

Have you previously had any soft tissue injuries?: *

Have you had any operations?: *

Do you currently have a gym membership? If not, are you willing to get one?: *

Yes

No

What is your fitness / training experience?: *

Complete beginner (new to the gym)

Beginner (have been to the gym occasionally)

Intermediate (have been going to the gym regularly for over 2 years)

Advanced (have been going to the gym consistently for over 3 years and have a solid understanding of exercises)

Very advanced (the gym is a part of my consistent lifestyle and I understand anatomy, resistance profiles and strength profiles)

What is your current exercise routine?: *

Which days are you able to do resistance/weight training?: *

Which days are you able to do cardio sessions?: *

Are there any other forms of physical activities that you do on a frequent basis?: *

How long have you been this physically active?: *

Do you currently train at least 3 times per week?: *

Yes

No

How many steps do you average per day (according to an activity tracker or smart phone health tracking app)? *