MK Nutrition Website

Name:

Address:

Tel:

Mobile:

E-mail:

where did you hear about us?

What is the reason for your enquiry?:

Do you take any prescriptive drugs?: state daily dosage

Do you take any supplements?:

Your Weight (without clothes):

Your Height (without shoes):

What is your normal blood pressure?:

What is your resting pulse rate per minute?:

What illness is/was our mother and father prone to?:

Do you have brothers and sisters that suffer from any particular illnesses?:

Do you exercise?: if so, what and how many times a week

How much sleep do you get a night?:

Do you make time for relaxation?: yes no

Do you smoke?: if yes, how much

Do you drink alcohol? If yes, how often and how much

Do you eat confectionery or chocolate?: yes no

Do you eat fast food?: yes no

Do you drink carbonated drinks?: yes no

Do you eat foods/drinks containing artificial sweetners?: yes no

Do you drink milk and eat dairy products?: yes no

Do you drink water?: yes no

Do you drink tea or coffee?: yes no

Do you eat pastries, cakes or biscuits?: yes no

Do you eat white or brown bread?: white brown

Do you eat meat?: yes no

Do you eat fish?: yes no

What percentage of your diet is fruit and vegetables?:

Does your job involve eating out a lot? yes no

Do you suffer pain?: yes no

Do you suffer from stress?: yes no

Do you suffer from low energy?: yes no

Do you suffer from allergy problems?: yes no