Client Application Form

Congratulations on making the decision to change your life. You will find your weight loss journey exciting and rewarding and we can't wait to get you started.

Completing this questionnaire

Answer every question - This is not the time to be shy! The more information you give us, the better we will be able to design a plan that suits you perfectly and your consultant will have an enhanced understanding of your life and requirements.

You may be unsure of how to answer some questions, We encourage you to pay particular attention to any medical problems or symptoms you have had in the past 12 months but also want to know about your long term health.

This form should take you about 15 minutes to complete. If you follow our program, we guarantee that you will succeed, losing your unwanted kilos and improving your overall health.

Dr JB Ryan
(Chief Medical Advisor)
and The Adventure Team

1 About You
Title	Mr Mrs Miss Ms
Surname
First name
Middle name
Date of birth
Age
Sex	Male Female
Phone - home
- work
- mobile
Email
Postal Address (this is where your plan and supplements will be delivered)
Suburb
Postcode
State
Did you hear about us from a health practitioner?	Yes No
What is the name of the practitioner?
What is the phone number of the practitioner?
What is the email address of the practitioner?
If you heard about us from another source, we would love to know how.	7 secrets book Internet search TV Radio Twitter/Facebook Print media Book review
If you heard about us from a friend, please let us know their details so that we can thank them.
Name
Contact phone
Email

2 Your Lifestyle
Present weight	kg
Height	cm
Build	small medium large
Shoe size
How many kilos would you like to lose?	1-6 kilos 7-12 kilos 13-18 kilos 19-30 kilos > 30 kilos
Please note that you will be given a goal weight by our doctor within your healthy range based on a medical calculation.
Do you do any exercise?	Yes No
If so, please list the type and regularity:
Do you drink alcohol?	Yes No
If so, approx, how many glasses per week?	glasses
Where are your worst problem areas?	arms breast neck waist stomach hips bottom thighs calves
Have members of your immediate family also experienced weight gain?	Yes No
Do you work night shifts?	Yes No
Men: go to "3 - Your Medical History" Women: answer these 4 questions, then continue to "3 – Your Medical History"
Are you pregnant or breastfeeding?	Yes No
Do you wish to become pregnant within the next 12 months?	Yes No
Have you been on IVF or intend to in the next 3 months?	Yes No
Are you peri menopausal (starting menopause), mid menopause or post menopause?	peri mid post none

3 Your Medical History
List any operations you have had or are planned for the future:
Have you ever suffered from any type of cancer?	Yes No
If yes, what type of cancer? How long ago was it diagnosed/ How long ago was your last treatment?
Do you have type 2 diabetes?	Yes No
If so, are you taking medication for diabetes and what is the name of the medication? If you are insulin dependant please contact our office before continuing with this form.
Please indicate any other conditions that apply to you:	Anaemia Bowel - give details below Cancer Candida Chronic Fatigue Coeliac Constipation Crohn's Depression Diabetes Dizziness Gall Bladder Gall Stones Heart - give details below Hepatitis High Blood Pressure High Blood Sugar Irritable Bowel Syndrome Low Blood Pressure Low Blood Sugar Lupus Psoriasis Reflux Stomach Staple Thyroid - give details below Ulcerative Colitis None
Details:
Other medical conditions / illnesses:
List all current prescription medications you currently take:
List all current over the counter medications you currently take:
List all supplements, vitamins and natural remedies you currently take:
Name of your regular doctor:
Phone:

4 You and Food
Please indicate any allergies that apply to you:	dairy MSG metabisulphite shellfish nuts none of these
Do you have a sensitivity to wheat/gluten? (Do you feel tired or bloated after eating it)	Yes No
Are you lactose intolerant?	Yes No
If so, which of these can you not eat?	cheese milk yoghurt other
Please list any other foods you cannot eat:
Have you ever been admitted into or attended hospital due to any drug, food or chemical reactivity?	Yes No
Have you ever had any drug or other food sensitivity or any chemical reactivity?	Yes No
If yes, details:
Are there any other details that you would like to bring to the attention of our medical team?	Yes No
If yes, details:

5 Agreement
I have read and accept the agreement: (click here to view)	Yes No

Client Application Form

1 About You

2 Your Lifestyle

3 Your Medical History

4 You and Food

5 Agreement