Name

First Name

Last Name

Contact Number *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Lifestyle Goal Discovery *

Please select from the following goals as they apply and are important to you.

Weight-Loss & Decrease Body Fat

Increase Strength & Lean Muscle Mass

Improve Endurance & Cardiovascular Health

Improve Mobility, Flexibility & Reduce Joint Pain

Focus on Personal Growth & Improve Mental Health

Create a Daily Structure & Optimize Routine

Improve Nutritional Habits & Food Selection IQ

Improve Digestion & Gut Health

Reduce Inflammation & Support Immune System

Optimize & Balance Hormones

Detoxification Remedies

Improve Sleep Quality & Recovery

Sleep Hygiene

Please select as many that apply to you.

Trouble Falling Asleep

Restless & Interrupted Sleep Hours

Regular Screen-Time Before Bed

Difficulty Waking & Starting Daily Routine

Infrequent Dreaming

Which types of meals do you prefer? *

Below is a list of various meal types categorized by the time of day. Please tick off the meal types you enjoy or would like to have included in your meal plan. This will help us customize a plan that aligns best with your tastes and preferences.

Yogurt Bowls / Porridge / Cereals: eg. Could be hot (like oatmeal) or cold (like cornflakes).

Smoothies / Shakes: eg. Fruit-based, protein-based, green smoothies, etc.

Eggs: Scrambled, eg. fried, poached, omelette, etc.

Pancakes/Waffles: eg. With various toppings.

Sandwich / Wrap: eg. Different fillings like turkey, ham, veggies, etc.

Salads: Caesar, eg. Greek, fruit salad, grain salads like quinoa or couscous.

Bowl Meals: eg. Rice bowl, grain bowl, poke bowl, etc.

Stir-Fry / Pastas: eg. Chicken, beef, tofu with various veggies.

Tacos / Burgers: eg. Beef, chicken, fish, veggie burgers, etc.

Snacks & Bites: eg. Trail mix, fruits, energy bars, veggies & dip, cheese & crackers, etc.

Program Start Date *

MM

DD

YYYY

Please confirm your legal name. *

First Name

Last Name