Questionnaire - Ljuba Pantovic

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Instructions Please fill in the form below, this will help understand basic habits, needs and ease creation of your diet and/or exercise plan. We will read the information and get in touch with you. If you think that any of questions is not relevant to your requirement feel free to skip the question but remember that more details you give more chances for successful and fast result.
First Name *
Last Name *
Address
City and ZIP
State
Phone Number *
Height *
Weight *
Gender
MaleFemale
Age *
Occupation
Working hours
Email *
Type email again *

Weight goal
Previous diets
How many hours you usually sleep?
How active you are and describe?
Do you have access to gym; if so describe your activity in the gym?
Do you have any psychical problems which can affect your activities and if so what kind of therapy you did for that problem?
Do you have any food allergies or intolerance and if so which?
Do you smoke or you quit recently?
Are you taking any medicine?
Do you cook for yourself?

Breakfast

Lunch

Dinner

Snacks

Breakfast

Lunch

Desert

Drinks

Rank salt intake
LowMediumHigh
What are your conditions to eat at work (describe do you have refrigerator, microwave, you order food have lunch break or get something from home)?
How much water do you usually drink per day?
How much alcohol do you drink per week?
Do you eat when you are sad/angry/bored… and explain
How would you describe your life at the moment in brief?
Describe your weight history?
Why do you want to lose / gain weight, describe your goals?
By sending this form I confirm that I personally filled in the form and that I take full responsibility for correctness of information and conditions of the program. *
Yes