Heart Guardian Info

Let’s get you back on track!

Hi there! I’m a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like piña coladas. (And gettin’ caught in the rain.)

…or something like this:

The XYZ Doohickey Company was founded in 1971, and has been providing quality doohickeys to the public ever since. Located in Gotham City, XYZ employs over 2,000 people and does all kinds of awesome things for the Gotham community.

Metabolic Balance Registration

Program registration info

Step 1 of 6

CLIENT INFORMATION
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth*
MM slash DD slash YYYY
Occupation*
Physician's name*
Physician's phone number*
Emergency contact name*
Emergency contact phone*
I would like to…*
- Lose weight
- Adjust my metabolism
How did you hear about our program?*
Did someone refer you?
If so, please enter their full name below. Leave blank if no referral

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HEALTH INFORMATION
Illnesses / Allergies
Please select from drop-down menu conditions that best describe your current health condition
Selection 1:
Select only one option
Selection 2:
Select only one option
Selection 3:
Select only one option
Medications
Please select from the dropdown menu below
Selection 1:
Select only one option
Selection 2:
Select only one option
Selection 3:
Select only one option
List all vitamins, mineral, herbs, drink supplements you are taking*
Have you been hospitalized in the past 5 years?*
Do you have a bowel movement every day?*
Do you strain to have a bowel movement?*
Do you experience digestive difficulties? Bloating, constipation, gas?*
How many times per day do you urinate?*
Are you regularly active in sports and/or exercise? If so, approximately how many hours per week?*
Do you have pets?*
If yes, what kind?
Do you smoke?*
- Yes
- No
If so, for how long? How much?
How many hours do you sleep at night?*
What time do you go to bed?*
What time do you wake up?*
Do you use antiperspirants that contain aluminum?*
Do you use antacids?*
(medication to neutralize stomach acidity)

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Eating Preferences
Eating preferences
Dislikes are categorized as: – General dislikes towards protein groups – Specific dislikes to individual food items If you select a protein group, e.g. meat, the plan will wherever possible, omit any type of meat. If for instance, you wish to exclude just one kind of meat, e.g. beef, you need to indicte this as a specific dislike under ‘other’ option. By doing so, other meats may be included in your plan. Please note: In some cases, it may not be possible to honor certain dislikes, for example, if omitting these foods would compromise a healthy diet
Selection 2:
Selection 3:
Selection 4:
Selection 5:

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Coaching is all about connection, care and support.

We help our clients navigate their priorities, values, and messy real lives

Metabolic Balance Registration

Step 1 of 6

CLIENT INFORMATION

Body Measurements Guide

HEALTH INFORMATION

Illnesses / Allergies

Medications

Eating Preferences

Extended Nutritional Information