Active Diet Fix Form

Homepage Active Diet Fix Form

BF Active Diet-Fix: Questionnaire

Below are the steps to signing-up to any BFunctional service.

Complete: the BF Questionnaire below [all client data is kept strictly confidential]
Payment: re-directed to Go Cardless [online Direct Debit specialist that manages the entire collection process on behalf of BFunctional]
Set-up: a one-off or monthly DD payment [GC will confirm your sign-up via email]
Re-directed: to the BFunctional website.
Confirmation: will be in touch within 48 hours.

Thank you and we look forward to working with you.

PERSONAL DETAILS

First Name

Last Name

Gender

DOB (DD/MM/YY)

Address

Mobile Number

Email Address

Emergency Contact Name

Emergency Contact Number

How did you hear about BFunctional?

LIFESTYLE

Do you consider yourself to eat Nutritiously?

Do you smoke daily/occasionally/never?

How much alcohol do you consume weekly?

How would you describe your level of stress?

How many hours sleep do you typically have p/night?

How many litres of water do you typically drink p/day?

NUTRITION:

How would you rate your diet in the past 6 months?

1 being "BAD" and 5 being "IMPECCABLE"

GOALS

What are your primary goal/s for joining the BF Nutrition Program?

Enhance my athletic endurance

Increase my physical strength and power

Prepare for my competitions

Weight (muscle) gain

Weight (fat) loss

Get fit and look great

Stay healthy and feel good about it

Other

Do you have any specific goals? If so, please explain below.

MEDICAL

Do you take any medications, either prescription or non-prescription regularly?

Do you know of any other factor which may affect your ability to follow this DIET-FIX program?

If you answered 'Yes' to any of the above questions please give more details below:

Do you have any other medical conditions we should be aware of, including relevant injuries? (If yes - please give details)

Please use the box below for any additional and relevant information:

Please read the BFunctional 'Nutrition Program' Terms and Conditions.

I agree to the terms and conditions

I agree

I understand that the details I have entered will be stored for contact purposes between myself and BFunctional

Are you human?