» Nutrition & Supplement

First name (Required) Last name (Required)

Date of birth(Required)

Gender(Required)

Marital status(Required)

Blood Group

Job(Required)

Education(Required)

Mobile(Required)

Email (Result sent via email)(Required)

Payment (40$ )

Please email transfer to: Dr.Bahrami@gmail.com or Paypal to: Dr.Bahraminejad@yahoo.com

The full name of the payer:(Required)

Date of payment(Required)

Payment receipt(Required)

Max. file size: 256 MB.

Current weight (measure your weight in the morning with underwear after toilet(Required)

Height (cm)(Required)

What is the usual stable weight?(Required)

Waist circumference (Measure the smallest circumference with a tape(Required)

Hip circumference (Measure the biggest circumference with a tape)(Required)

3 points priorities of body fat distribution (Priority 1)(Required)

Second priority

Third priority

Which of the following is more common in your family?

Fat percentage (with caliper or body composition analysis device)

Have you used a diet before?

Mention the main reason for your lack of success in the previous diet plan(Required)

What is your purpose for requesting a meal plan?(Required)

Do you need to change your weight to compete?

Mention the type of disease along with the drugs used(Required)

Which method do you choose to change weight?(Required)

In how many months do you want to change your weight?(Required)

How much weight change is optimal for you?(Required)

Rate the difficulty of your requested diet from 1 (easiest) to 5 (hardest).(Required)

Have you ever had a certain disease?(Required)

Mention the type of illness and its duration(Required)

Have you had surgery?(Required)

Mention the type and time of surgery(Required)

Do you suffer from digestive problems or digestive disorders?(Required)

Explain the type of digestive problem and its duration(Required)

Do you take any special medicine?(Required)

Explain the type and amount of medicine(Required)

Do you have a food allergy?(Required)

Please explain the type of food and your symptoms

Which of the following do you use?(Required)

Do you get heart palpitations with coffee and tea?(Required)

How many cups of tea or coffee do you drink a day?(Required)

Do you have healthy teeth?(Required)

Do you have a good sleeping position?(Required)

Assess your job stressors(Required)

How many meals do you eat during the day?(Required)

Do you eat your food on time?(Required)

What is the reason for not eating on time?(Required)

Do you wake up during the night to eat ?(Required)

If you eat at night, what kind of food do you usually eat?(Required)

Do you eat vegetables with your food?(Required)

Do you drink water before or with food?(Required)

Do you serve your food one time or more?(Required)

Do you eat your food quickly and without complete chewing?(Required)

Are you used to eating?(Required)

Please specify its type and amount exactly

Do you usually skip a meal from your main meal?(Required)

Which meal do you usually skip?(Required)

Do you habitually have a special prohibition in consuming a certain type of food?(Required)

Please specify its type

Do you have a particular desire to consume more of a certain type of food?(Required)

Please specify the type of food(Required)

Do you have a particular desire to consume more of a certain type of fruit(Required)

Please specify its type

How many minutes a day do you usually do physical activity?

What kind of drinks do you use most during the day, choose two at most

Water

Tea

Coffee

Soft drinks

non-alcoholic beer

Fruit juice

Sports drinks

Do you use sugar or other sweeteners?

Please explain the amount in full(Required)

Write down two examples of your breakfast, mentioning the exact amount of food consumed(Required)

Write down two examples of your lunch, mentioning the exact amount of food consumed(Required)

Write two examples of your dinner, mentioning the amount of food consumed exactly(Required)

As a snack in the morning and evening, what foods and drinks do you usually eat and how much?(Required)

How much water do you drink on average per day?(Required)

Do you feel weak and lethargic by consuming less food?

Have you already received the nutrition program from the site?

In what language would you like to receive your training plan?(Required)

Please, in addition to criticisms and suggestions, if you think there is something special that is not mentioned in the form, write it below.

If possible, please send the zipped file of your medical documents and tests

Max. file size: 256 MB.

Body composition file

Max. file size: 256 MB.