Nutrition Questionnaire

Please complete this form

In order to get to know you alittle bit better, we need to ask you a few questions.

Do You Have Any Medical Conditions?

Yes No

Do you take medication.

Yes No

Have you injuries to ligament or tendons Joint etc.

Yes No

Do you have allergies to anything.

Yes No

Do you have any other diseases or complaints

Yes No

When was the last time you have a blood test

Do you smoke

Yes No

Do you drink alcohol

Yes No

How often do you go to the toilet per day

How many hours do you sleep per day

Have you ever had problems with your weight, what is the problem?

Yes No

If yes, please specific

Have you tried to diet before, what happened

Yes No

If yes, please specific

What Are Your Short and Long-Term Goals? ..

What’ foods do u like

Name

Phone Number

Email

Line ID

Step with * is mandatory.

Bangkok, Thailand