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Blood Work Consultation
Step
1
of
3
33%
You are about to begin your VIP Blood work online consultation with Jake
I am diving in to understand your current diet, exercise, and most importantly GOALS.
Personal Details
Name
*
First
Last
Email
*
Contact Number
*
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Age
*
Gender
*
Male
Female
Height
*
Write number only in Cm
Weight
*
Write number only in KGs
Please submit a front and back full photo for us to see your body composition
We will use photos throughout our journey to track your performance and results
Front photo
*
Max. file size: 100 MB.
Back photo
*
Max. file size: 100 MB.
Is this your first time working with us?
*
Yes
No
Medication, Illness, Intolerances & Allergies
We need to dive deep into your current health so we can know all the factors that contribute to your diet. Remember I the terms and conditions we do recommend having a medical checkup. Whether you choose to do so or not is your decision.
Do any of the following apply to you?
*
Pregnant
Breast feeding
None of the following
Please only select one option
How long have you been breastfeeding for?
*
Are you allergic or intolerant to any foods?
*
Yes
No
Please explain the intolerance or allergy and its affects
*
Are you taking any medication or suffer from any illnesses?
*
Yes
No
Please explain medication or illness
*
Have you ever experienced or currently have an eating disorder?
*
Yes
In the past, yes
No
Please describe this in further detail:
*
Please describe this in further detail:
*
Do you have a menstrual cycle?
*
Yes
No
How long is your cycle?
*
How long since your last cycle?
*
Are you on any contraception?
*
Yes
No
Are you using or have used any PED?
*
Yes
No
Physical Activity
We need to understand what type of physical activity you are currently doing or able to get into your day to help us build a plan to achieve your goal.
Explain your current exercise regime; Frequency, time of day, duration and type of training/splits.
*
Current Diet & Habits
Be honest and let us know everything! Foods you like, dislike, current habits and anything else we should know. The more information the better we can work with to create the best plan for you.
What is your current diet, list calories and macros if tracking your food?
*
Please write down everything you eat and drink including the time and quantities. Do not try to change your eating habits during the Three Day Food Log.
*
What are you hoping to achieve with this service?
*
Please list any other relevant information for your blood work review
Please tick yes that you understand you will also require to pay for your own blood work on top of this review
*
Yes, I understand
SHOP
SERVICES
Lifestyle Premium
Performance Coaching
VIP Coaching with Jake
One-off Nutrition Plans
CALORIE CALCULATOR
FREE RECIPES
TRANSFORMATIONS
CONTACT US
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