Step 1: Basic Information

Name Age Gender FemaleMaleOther Email Phone Number

Step 2: Clinical and Dietary Data

Medical History (Check all that apply): Diabetes (Type 1, Type 2)High Blood PressureHigh CholesterolThyroid Disorders (Hypo/Hyper)Gastrointestinal Disorders (e.g., Acid Reflux, IBS)NoneOthers Current Medications or Supplements: Dietary Preferences: VegetarianVeganNon-VegetarianPescatarian Food Intolerances or Allergies (Check all that apply): GlutenDairyNutsShellfishNone Daily Water Intake: Less than 1 liter1-2 litersMore than 2 liters

Step 3: Lifestyle and Goals

Activity Levels: Sedentary (Minimal Movement)Lightly Active (Occasional Walks or Light Activity)Moderately Active (Exercise 2-3 times a week)Very Active (Daily Exercise or Heavy Workload) Stress Levels: LowModerateHigh

Sleep Patterns

Hours of Sleep Per Night: Less than 5 hours5-7 hoursMore than 7 hours Quality of Sleep: PoorFairExcellent Primary Health Goal (Select one or more): Achieve a Healthy WeightManage a Medical Condition (e.g., Diabetes, PCOS)Improve Gut HealthBoost Energy and FocusEnhance Sports PerformanceOther What Motivates You to Make a Change? What Motivates You to Make a Change?Prevent Future Health IssuesSupport Ongoing Medical TreatmentEnhance Quality of LifeEnhance Quality of Life Preferred Support (Choose one or more): Personalized Diet PlanOne-on-One Health Coaching (ATP, BTP, CTP Programs)Access to Recipes and ResourcesLong-Term Subscription Plan Your message (optional)