Your details will be held in the strictest confidence and not past on to any third-party.
Date of Birth:
Water (H20) intake daily:
Are you a Vegetarian?
Are you a Vegan?
Do you smoke?
If you do smoke, how many do you smoke per day?
Do you drink alcohol?
If you do drink alcohol, what type(s) do you drink?
How often do you drink alcohol?
How many units per day?
Do you know the calories per unit?
Are you worried about your intake?
Caffeine intake/cups of coffer per day:
How much sugar do you add to your drinks and food per day?
Do you have an illness or past illness we need to know about?
If yes, please can you give us a little more information:
If you suffer from any food alergies please can you list which ones?
Do you currently take any medication for a medical condition?
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