KETOZERO - Health Evaluation Form

HEALTH EVALUATION FORM

The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete.
Full Name*

First NameLast Name
Profession (Details)*
Location (Residence)*
Mobile *
How did you get to know of 'KETOZERO'?*

WebsiteFacebookInstagramYou TubeLinkedINReferenceOther
Gender*

MaleFemale
E-mail

GENERAL INFORMATION
Medical history of illness in recent 2Years & current medication details (if any) Please upload relevant medical reports*
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Date of Birth*

MonthDayYear
Height *
Weight *
Upload your latest (last 3 months) picture here :

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What is your current Body Fat %?*
Blood Pressure (Month & Year of Recording)*
What are your main goals & expectation from "KetoZero" Diet Plan?*

Weight lossDetoxDisease PreventionDigestive SupportDietary AdviceEnergyImmune SystemSports EnhancementOther (Details)
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health
Reason for the rating
How do you rate your current level of energy or vitality
Reason for the rating
How do you rate your current stress levels
Reason for the rating
How many hours sleep do you get a night?*
Do you have trouble getting to sleep?*
Do you have to go to the bathroom during the night?
Do you snore or have breathing problems during sleep?*
Do you have known food allergies?*
Please list any known food allergies*
Please list any medications / laxatives you are currently taking*
Please list any supplements you are currently taking*
Do you have a main health complaint? Please describe.
Additional info you might want to share
Next: Diet and lifestyle . .

Do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
Please list the types of exercise you do regularly
Do you smoke?*
How many per week?
Do you take recreational drugs?*
Please list any food allergies / intolerance that you are aware of?*
How many glasses of water do you have a day?
Do you drink alcohol?

YesNo
How many per week?*

Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
Kindly narrate your ideal meals / liquids consumed on a typical day.
Individual results are not guaranteed and may vary from person to person. The nutritional success depends on each individual’s background, dedication, desire, and motivation.This meal / diet plan is not intended to diagnose, treat, cure any disease and is not a medical advice. All information presented and written within this document / website are intended for nutritional informational purposes only pertaining to food and dietary supplements.The advice and meal plans are undertaken voluntarily at one’s own discretion & we do not hold liability for any allergic reactions / other conditions that may arise during or post the diet consultation tenure. The diet plan is designed relying upon the varsity of the information given in the “KetoZero – Health Evaluation Form” and during the consultation sessions.*

I acknowledge that I have read and agree to the above Terms and Conditions
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HEALTH EVALUATION FORM