Nutrition Assessment

Name *
Name
If you are sure just write "unsure" in the text box below. If you have something specific you are working on not related to weight loss, please provide details in the text box below.
For example what specific/special diet programs have you tried?
Ex. surgeries, procedures, medical concerns, etc.
Please list the name, dose and frequency you take them.
Do you smoke? *
Do you drink alcohol? *
Please list at least 3
Excluding juice and dried fruit
Please list the name, dose and frequency you take them.
10 being the most confident