ediet questionnaire
Anti-Aging-Plan.com

Life extension and
disease treatment through
periodic fasting and
caloric restriction -
the most powerful
scientifically proven
natural anti-aging method

 
Calculate your BMI
(Body Mass Index)

BMI Categories:
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater

METRIC STANDARD
Your Height: cm
Your Weight: kg
Your BMI:

 
e-Coaching Questionnaire

Please fill in the following questionnaire and we will create individually adjusted anti-aging water fasting weight-loss plan for you.
Attention please! We are not machines! Your request will be supervised and analyzed manually by our nutritionist, medical doctor and anti-aging expert.

PERSONAL DETAILS

* Denotes mandatory fields.
First Name*
Last Name*
Address *
 
 
Zip/Postal code*
City*
Country*
 
 
Mobile Phone*
E-mail*
Skype
Weight* lbs kgs
Height*  ft    cm
Age*
Profession/Occupation
                             Male Female
   Gender

Choose from the list the diseases that you have already had or are predisposed to:
(We advise this health questionnaire to be filled out in collaboration with
your personal physician)
bronchitis
 
asthmatic bronchitis
 
bronchial asthma
 
tonsillitis
 
maxillary sinusitis
 
coronary heart disease
 
angina pectoris
 
atherosclerosis
 
trombophlebitis
 
hypertension (point pressure values)
ulcer
 
gastritis (hyperacid, normacid, anacid)
 
cholecystitis
 
colitis
 
enterocolitis
 
chronic pancreatitis
 
chronic hepatitis
 
hemorrhoids
 
pyelonephritis
 
glomerulonefritis
 
nephrostone disease
 
radiculitis
 
arthritis & polyarthritis
 
articular rheumatism
 
arthritis uratica
 
osteochondrosis
 
osteoporosis
 
diabetes, compensated, II type
 
neurosis – indicate diagnosis
thyroid gland disease (point out the character of dysfunction)
anemia (point the origin)
cutaneous diseases (of what kind)

non-food allergy (point the causation factor if you know it)
 
food allergy (to what kind of food)

other diseases:
 
Which diseases have you previously suffered from, and when?
 
 
 
Check one answer that best describes your level of physical activity
 Competitive athlete
 
Sedentary - not active or bare minimum for daily needs such at weekly chores.
 
Limited physical activity - gardening, walking, cleaning but does some movement of                 that type daily
 
Recreational activity ("week-end athlete")
 
Physically fit, non athlete, regular exercise routine
 
Other 
 
Women only
 
                                                      Pregnant     Yes No
                                             Breastfeeding     Yes No
 
 
We will create for you the personal Diet Plan for one week, two weeks, three weeks and four weeks. Please chose your option:
 
1 week   (price EUR 100)
 2 weeks  (price EUR 150)
 3 weeks  (price EUR 200)
  4 weeks  (price EUR 250)
 
Cyclic fasting anti-aging coaching Plan will be sent to you. 
Attention! If you have no previous experience in fasting we adise you to include in your Anti-Aging Plan not more than 3-4 fasting days per week.

Choose the number of days you would expect to fast (3 ... 21):
_____________________________________________________________

Choose Your Goal

Lose 5 - 20 pounds (2 kg - 9 kg)

Lose 25 - 50 pounds ( 10 kg – 22 kg)

Lose more than 50 pounds ( 22 kg )

Maintain weight
Gain weight, 5 - 20 pounds (2 kg - 9 kg)
Gain weight, 25 - 50 pounds ( 10 kg – 22 kg)
Gain weight more than 50 pounds ( 22 kg )
____________________________________________________________

Additional comments, special requirements:
Security code:
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