Online Consultation

Simply fill in the questionnaire and submit for a quotation on an individualized eating plan via email. This service is medical aid friendly! All information submitted is kept CONFIDENTIAL.

Name and Surname
Telephone / Cell Phone
Email
Preferred Language	Afrikaans English
Medical Aid:
Name
Plan
Member Number
Sex	Male Female
Age	years
Weight (kg)	kg
Height (cm)	cm
Waist (cm)	cm
Hips (cm)	cm
What is your occupation?
Do you smoke?	- Please select - No, I don't smoke Less than 5 per day 5-10 per day 10-20 per day 20-30 per day More than 30 per day
Do you exercise?	- Please select - No, I don't exercise 1 time per week 2 times per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week
Type of exercise?	- Please select - Weights Cardio Walk the dog
How much alcohol do you consume?	- Please select - None Little Moderate High Excessive
Please list any chronic illnesses, if any
Do you have any blood results on the following?	None Total Cholesterol LDL Cholesterol Triglycerides Fasting Glucose Insulin Uric Acid
Do you suffer from any of the following?	None Stomach cramps Constipation Diarrhea Reflux Heartburn Excess Gas Food Intolerance Food Allergies High blood pressure Diabetes High cholesterol
Any other?
Have you been on any slimming diets?	Yes No
Is your weight fluctuating?	Yes No
List current medication
List current supplements
What do you cook with?	Butter Oil Margarine
What do you usually have for breakfast?
What do you usually have for lunch?
What do you usually have for dinner?
What do you snack on?
Morning:
Afternoon:
Late Night:
Do you binge eat?	Yes No
How often?

How much of the following do you consume?	Per Day	Per Week
Milk
Full Cream
2% Fat
Fat Free
Yoghurt
Low Fat
Fat Free
Fruit
Fresh
Dried
Canned
Juice
Vegetables and salads
Cooked
Raw
Bread
White
Brown
Seed or Wholewheat
Low GI / Best of both

Do you know what you are doing wrong and keeping you from achieving your ideal weight or health?
Other comments

Reload Image

Enter code:

Contact Person:

Sonelle van der Linde
69 Morningside
1 Isak de Villiers Street
Langenhovenpark
Bloemfontein
South Africa

Contact Details:

Cell: 076 3385367
or
Send me an