Food is your best medicine. Consultation and patient questionnaire form.

Request for a nutrition consultation and a diet plan for:

An Illness

Weight reduction

Pregnancy

An athlete

Personal and health data sheet

Please fill out this form after you have visited the pages below

Personal information
Full name
e-mail address
Telephone (country + city + number)
Fax (if applicable)
Street Address
City & Country
Profession
Date of birth
Weight now (indicate kg or lbs)
Weight 1 year ago (indicate kg or lbs)
Desired Weight (indicate kg or lbs)
Height (indicate cm or inch)
How did you hear about our website?
Your eating habits
Breakfast
Lunch
Dinner

Marital status	married single
Smoker?	yes no

Your brief medical history

If you need to send a medical report (lab results, MRI report, etc.)

please scan and send as an attachment to this e-mail: tolaymat@hotmail.com

Current medications

Have you tried extreme weight loss methods

(i.e., Atkins diet, etc.)?

Consultation fee payment details

Money transfer

Credit card

enter payment transaction code and date below

(do not enter your credit card number here. To pay with a credit card now press here)

Preferred method of sending your diet plan to you

e-mail

Fax

e-mail address or fax number (country code + city code + number)

We will send your detailed diet plan within 24 hours of the time we receive:

1. This form completed

2. Your consultation fee payment

Thank you