Free Nutritional Profile
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Barbara Colby

Barbara H. Colby NSCA-CPT
Advocare Independent Distributor
Wellness Consultant

Phone: (561) 756-1290

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Free Nutritional Profile

Click for a FREE Nutritional Profile

So that I may evaluate your current nutritional situation, please complete the form below. This information will help me to design and suggest a program to fit your individual needs. All information is kept strictly confidential.

Your Name:
Home Phone:
Work Phone:
Cell or Pager:
Best time and way
to reach you:
  1. What is your gender? Male Female

  2. What is your age? Years

  3. Are you pregnant or nursing? Yes No

  4. List all supplements and medicines that you are currently taking.

  5. What do you eat for breakfast?

  6. Do you do physical exercise during the week such as jogging, walking, biking, etc.? Yes No

  7. Do you have any medical conditions, injuries or limitations? If so, what are they?
    Yes No

  8. Do you retain water? Yes No

  9. Do you ever experience indigestion? Yes No

  10. Are there foods that upset your stomach or that you are allergic to? If so, what are they?
    Yes No

  11. VERY IMPORTANT, so please be honest. Which best describes your frequency of bowel movements?

  12. Do you drink coffee or soft drinks? If so, how many per day?
    Yes per day No

  13. How much water do you drink per day (glasses/ounces)?

  14. Check which habits you think caused your weight gain:
    Late meals
    Too many sweets or carbohydrates
    Junk food
    Too busy to eat right

  15. How many pounds or sizes do you want to lose?
    Pounds: Sizes:

  16. Are you willing to commit to your program for at least 90 days? Yes No

  17. How did you find our Web site?

  18. How do you wish to purchase products? Retail Wholesale

Thank you! Barbara will contact you shortly.

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Advocare Distributor

Barbara H. Colby NSCA-CPT
Advocare Independent Distributor, #0002614
Family Fitness & Nutrition

(561) 756-1290 |

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