Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
City
Country* Country United States Canada United Kingdom Australia ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States of Micronesia Moldova Monaco Mongolia Montserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (former) Zaire Zambia Zimbabwe
Gender*
---Select--- Male
Female
Year of birth*
Height in centimeters*
Weight in kilograms*
Your phone number including country code*
What program will you use for the consultation?*
---Select--- WhatsApp
Skype
FaceTime
What is your id, or phone number (inc country code) for the above?*
What is your MAIN health concern?*
Any other health problems?*
What medication(s) are you taking?*
What vitamins/ herbs are you taking?*
Do you exercise? Which and how often?*
Do you eat any organic foods? Which and how often?*
How much stress do you have daily?*
How many cups of coffee do you drink every day?*
I eat at least 3 vegetables daily for lunch and dinner*
I eat fruits (oranges, bananas, kiwi, mangoes, apples, pears, etc..)*
I eat chicken*
I eat beef*
I eat pork*
Other meat you eat*
I eat eggs*
I eat fish or other sea food*
How many times a week do you use oil for frying or in salads?*
Specify how many times a week you eat the following: avocados, nuts, seeds, coconut flesh, other oily food*
I eat gluten products such as bread or cakes or biscuits or floury products (i.e. pasta..) or wheat food *
I eat chocolate or other sweets*
I eat dairy products from cow, goat, sheep, etc..*
I eat tin food or pre-prepared meals*
I always check products labels to make sure I don't eat sugar*
I always check labels to make sure I don't eat any harmful chemicals (additives, coloring, etc..)*
IMPORTANT: If you have only recently changed your diet from the above. Please state WHEN you changed it, and what your previous diet was?*
I smoke*
I drink alcohol*
Other Comments*
How did you hear about my consultation?*