Personal form
Please fill in your personal data:
Phone number (please select area code by clicking the flag)
Your Instagram account (if any)
Residence country/city
How did you Learn about me?
Your natural dat:
Your weight when you were 18-19 yo ( If applicable)
Most significant weight changes since this age (age/weight)
What did you do tolose weight ever before?
What is your most comfortable weight?
Health condition info
Have you had any weight changes during the past year? If yes - please tell more
Did your parents or grandparents have any extra weight or type 2 Diabetes?
Tell me if you have any gut issues (Heartburn, stomach ache, sickness, vomiting , or any other troubles ) ?
Any issues with bowl movement?
How often do you have bloating or gases ?
When you had your blood analysis last time ? Please send me if recent
Do you know your blood glucose level ?
Do you take any medication or supplements ? If yes - please list them.
Do you know your Vitamin D level ?
DO you have any back pain, or any other back issues? (Hernias, etc. Did you do an MRI screening recently? )
What’s your typical blood pressure level? Normal, high, or low ?
Are you allergic to any foods? Please list
Do you see an Endocrinologist currently ? If yes - please advise the reason
Have you ever done your Thyroid screening? If yes - please let me know the result
Any diseases, injuries you ever had? Please list with the date when
Any chronic diseases?
Please evaluate your daily average stress level from 1 to 10
Do you normally have a breakfast?
Which groats do you eat?
Which fish do you prefer ?
Which meats do you prefer?
Do you normally eat fruits and vegs? Which ones and how often?
Do you like to have soups?
How much water do you drink per da?
How many coffee cups do you have per day? (With mIlk?)
Do you add sugar into your tea or coffee ? If yes - how much ?
Do you eat any fast food ? How often ?
How much backed goods or sweet pastry do you eat per day ?
Do you take alcohols ? Ready to cut it for a while ?
Do you smoke? How long ?
How many meals per day do you normally have?
Do you use a computer/telephone while eating?
Do you happen to eat when not hungry, but bored or upset, etc?
What time do you go to bed normally ?
What time do you normally get up in the morning ?
Your Activity
Do you everwalk ?
Do you exercise normally? Or when was the last time
Do you have a gym or swimming pool available ? Or a possibility to walk?
Do you have any children?
What do you want to have from a nutritionist (me)?
Please write a few lines about yourself and your plans for the coming 3-5 years
5 words about yourself (Adjectives )
Imagine you have your dream weigh and body already, what becomes possible then ?
Are you ready to take the responsibility required for your food habits change and general lifestyle changes ? Yes or No ?
ИП Давыдова О. А. (ОГРНИП 319774600327716 ИНН 771393736220)