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Name:

E-Mail Address:

Age

Male / Female

Weight

Height

Goal Weight

Do you suffer from sinus

Do you suffer from post nasal drip

Do you suffer from headache

Do you suffer from stomach bloating

Do you suffer from constipation

Do you suffer from diarrhoea

Do you suffer from stomach cramps

Do you suffer from joint pains

Do you suffer from Skin conditions like eczema / rashes / hives

Do you suffer from flatulence

Do you suffer from inability to concentrate

Do you suffer from fatigue

To your knowledge do you suffer from any food intolerance’s.

Do you suffer from high cholesterol

Do you suffer from low sugar levels

Do you suffer from gout

Do you suffer from non-insulin dependant diabetes

Do you suffer from insulin dependant diabetes

Have you been diagnosed with any other diet related medical problems?

Food dislikes:

14 day Detox Program R250.00

Waistline Slimming Plan R600.00

Additional Waistline Slimming Plans R250.00

Waistline Slimming for Life Plan R300.00

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NOTHING CONTAINED IN THE WEBSITE IS INTENDED TO CONSTITUTE,NOR SHOULD IT BE CONSIDERED,MEDICAL ADVICE OR TO SERVE AS A SUBSTITUTE FOR THE ADVICE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER. WE MAKE NO ASSURANCES OF THE INFORMATION BEING FIT OR SUITED TO YOUR MEDICAL NEEDS,AND DISCLAIM ANY IMPLICATIONS OF ANY CONTENT OR ADVERTISEMENT ON OUR WEBSTE BEING FIT AS PER THE PRACTICE OF MEDICINE. NOTHING CONTAINED IN THE WEBSITE IS INTENDED TO GIVE RISE TO,NOR SHOULD IT BE CONSIDERED AS GIVING RISE TO,A DOCTOR PATIENT RELATIONSHIP.
Do not embark on any eating plan before consulting your physician
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