Diobat - Member of Independent Herbalife - Member of Independent Herbalife valence, Herbalife products

Full name

Telephone of contact

Profile of Instagram, Facebook or both

Present weight

Height (In centimetres)

Perimeter abdomen (around the navel)

Date of birth

Age

1. Whichever meals you realise to the day?

One

Two

Three

Four

Five

More than five

2. Normamente usually you have breakfast?

Ground not to have breakfast

Breakfast with baker's shop (milky coffee or and baker's shop)

Only volume a drink (coffee, milk, vegetal drink or juice)

Breakfast with healthful foods (milky Coffee or, juice, cereals, bread, ham, oil, cakes, etc.)

3. Comes fruit and on a daily basis minimal vegetable 5 to 6 pieces to the day?

4. You include fish in your habitual diet?

Never or once for week

Two or three times per week

Four or more times per week

5. You have some nourishing restriction?

If (I cannot take)

6. Whichever water you ingest daily?

Half liter

A liter

More of a liter

More than two books

7. Usually you take exciting drinks, as coffee, tails, energy, etc?

No, never

If, every day

If, sporadically

No, since it does not feel caffeine well to me

8. With what frequency you go to the bathroom to do of belly?

on a daily basis

Every two days

Every three or four days

I have difficulty to go to the bathroom

9. You have heavy digestions?

10. You think that you have a optimum level of energy?

11. You realise some physical activity?

If Which?

12. What type of plan it would like to follow?

13. It has or it has had some type of disease?

I have read and acceptable the Policy of privacy.

Attention: The fields staked out with * are obligatory.

Questionnaire of nutritional habits.