Please fill out the health quiz below so that we can get started on your program as soon as possible. Health Quiz Note: If a question doesn’t apply to your plan, please enter “N/A” or feel free to leave the answer space in blank. Name * First Name Last Name Email * Phone number (with area code) Gender Date of Birth Height Current weight (please specify if lbs or kg) Surgery Date * MM DD YYYY Name of your surgeon or clinic (that will perform the surgery) * Do you suffer from any type of heart problems, cardiovascular or chronic disease? If so, please describe. Do you take any new medications? If so, please specify. Do you have any food allergies or intolerances? Are there any foods you dislike? Do you follow a particular type of diet? If so, please describe. Examples include: Regular diet, Vegan, Vegetarian, Intermittent Fasting, Keto, etc. Have you had any of the following surgeries: Gastric Sleeve, Bypass, Mommy Makeover, Tummy Tuck or any other physical surgery? If so, please describe and when was your surgery? Do you currently do any type of physical activity? If so, please describe: Are there any additional comments you would like to share with us? Thank you!
