Please be patient and fill in the required information carefully Nutrition & Supplement Step 1 of 7 14% (Required) First name (Required) Last name (Required) Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)malefemaleMarital status(Required)SingleMarriedBlood Groupo+o-A+A-B+B-AB+AB-Job(Required) Education(Required)DiplomaBachelorMasterPHDMobile(Required)Email (Result sent via email)(Required) Payment (40$ )Please email transfer to: Dr.Bahrami@gmail.com or Paypal to: Dr.Bahraminejad@yahoo.comThe full name of the payer:(Required) Date of payment(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Payment receipt(Required)Max. file size: 2 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)front of abdomenthe sideshipthighchesthandsSecond priorityfront of abdomenthe sideshipthighchesthandsThird priorityfront of abdomenthe sideshipthighchesthandsWhich of the following is more common in your family?ObesityThinnessproportionalMuscularFat percentage (with caliper or body composition analysis device) Have you used a diet before?NoYesMention the main reason for your lack of success in the previous diet plan(Required) What is your purpose for requesting a meal plan?(Required)Balanced dietWeight LossWeight GainCure the diseaseDo you need to change your weight to compete?NoYesMention the type of disease along with the drugs used(Required) Which method do you choose to change weight?(Required)Only with dietBalanced diet and fat burning supplementsWeight loss diet and fat burning supplementsBalanced diet and bulking supplementsWeight gain diet and bulking supplementsIn how many months do you want to change your weight?(Required)1 month2 months3 months4 months5 months6 monthsHow much weight change is optimal for you?(Required)Rate the difficulty of your requested diet from 1 (easiest) to 5 (hardest).(Required)12345 Have you ever had a certain disease?(Required)NoYesMention the type of illness and its duration(Required) Have you had surgery?(Required)NoYesMention the type and time of surgery(Required) Do you suffer from digestive problems or digestive disorders?(Required)NoYesExplain the type of digestive problem and its duration(Required) Do you take any special medicine?(Required)NoYesExplain the type and amount of medicine(Required) Do you have a food allergy?(Required)NoYesPlease explain the type of food and your symptoms Which of the following do you use?(Required)nonecigarettesalcoholCigarettes and alcoholdrugsDo you get heart palpitations with coffee and tea?(Required)NoYesHow many cups of tea or coffee do you drink a day?(Required)Do you have healthy teeth?(Required)NoYesDo you have a good sleeping position?(Required)NoYesSometimesAssess your job stressors(Required)LowMediumHigh How many meals do you eat during the day?(Required)12345IrregularDo you eat your food on time?(Required)YesNoSometimesWhat is the reason for not eating on time?(Required) Do you wake up during the night to eat ?(Required)NoYesSometimesIf you eat at night, what kind of food do you usually eat?(Required) Do you eat vegetables with your food?(Required)NoYesSometimesDo you drink water before or with food?(Required)NoYesSometimesDo you serve your food one time or more?(Required)NoYesDo you eat your food quickly and without complete chewing?(Required)NoYesAre you used to eating?(Required)NoYesPlease specify its type and amount exactly Do you usually skip a meal from your main meal?(Required)NoYesSometimesWhich meal do you usually skip?(Required)lunchbreakfastdinnerDo you habitually have a special prohibition in consuming a certain type of food?(Required)NoYesPlease specify its type Do you have a particular desire to consume more of a certain type of food?(Required)NoYesPlease specify the type of food(Required) Do you have a particular desire to consume more of a certain type of fruit(Required)NoYesPlease 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?NoYesPlease 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)1 liter2 liters3 liters4 litersUnknownDo you feel weak and lethargic by consuming less food?NoYes Have you already received the nutrition program from the site?NoYesIn what language would you like to receive your training plan?(Required)EnglishPersianPlease, 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 testsMax. file size: 2 MB.Body composition fileMax. file size: 2 MB.
