Your Personalized 30-Day Meal Plan

Personalized Nutrition Form

Discover our comprehensive and detailed form, designed to create a truly personalized nutrition program, taking into account every aspect of your health and lifestyle.

• 1Contact and Personal Information:
  • Identity: Full name, first name.
  • Contact: Email address, phone number
  • Demographic data: Date of birth, gender
  • Female Specifics: Questions about pregnancy, breastfeeding, and menopause.
  • Measurements: Height, current weight.
• 2Medical Conditions and History:
  • Chronic Diseases:
    • Diabetes (type 1 and 2 with details, gestational).
    • Hypertension, hypercholesterolemia, kidney failure.
    • Digestive diseases: Celiac disease, Crohn's disease, Ulcerative colitis, Irritable Bowel Syndrome (IBS).
    • Other: Gout, Iron-deficiency anemia, Fibromyalgia, Polycystic Ovary Syndrome (PCOS).
    • Thyroid: Hypothyroidism, Hyperthyroidism (multiple selection).
  • Autoimmune Diseases: Space to specify other conditions (e.g. Lupus, Multiple Sclerosis).
  • Other Important Medical Conditions: Open field for any unlisted information.
  • Sensitivities and Allergies:
    • Intolerances (lactose, histamine).
    • FODMAP-free diet.
    • Food allergies (peanuts, seafood, gluten, eggs, soy, nuts, etc.).
    • Food intolerances (wheat, corn, certain fruits, etc.).
  • Interventions and Special Conditions:
    • Multiple pregnancy.
    • Patients on dialysis.
    • Autism spectrum disorders.
    • Post-surgery (specify type).
• 3TCM (Traditional Chinese Medicine) Energy Imbalances:
  • General Syndromes (according to the Eight Principles): Cold, Heat, Deficiency, Excess, Exterior, Interior, Yin, Yang.
  • Zang-Fu Syndromes (Organ and Viscera): Multiple selection for each organ (Lung, Large Intestine, Spleen/Stomach, Heart/Small Intestine, Kidney/Bladder, Liver/Gallbladder) with a comprehensive list of specific imbalances for each.
  • Specific Syndromes: Qi Deficiency, Qi Stagnation, Blood Deficiency, Blood Stasis, Yin Fluid Deficiency, Dampness Accumulation, Phlegm Accumulation.
  • Bi Syndromes (Painful Obstruction): Types of Bi (Wind, Cold, Dampness, Heat, etc.) and their combinations (multiple selection).
  • Three Burners Syndromes (San Jiao): Imbalances of Upper, Middle, and Lower Burner (multiple selection).
  • External Pathogenic Factors: Invasion of Wind, Cold, Heat, Dampness, Dryness, Summer Heat, and their combinations, Toxic Heat (multiple selection).
  • Internal Pathogenic Factors (emotions): Anger, Excessive Joy, Sadness, Anxiety/Worry, Fear/Shock.
  • Gynecological Syndromes (women-specific):
    • Menstrual: Qi and Blood Deficiency, Liver Qi Stagnation, Blood Stasis, Heat in the Blood, Cold in the Uterus, Damp-Phlegm, Liver and Kidney Yin Deficiency (multiple selection).
    • Pregnancy: Spleen Qi Deficiency, Liver Blood Deficiency, Kidney Yin Deficiency, Qi and Blood Stagnation, Heat-Dampness in the Uterus, Liver Yang Rising, Kidney Deficiency (multiple selection).
    • Postpartum: Blood Deficiency, Blood Stasis in the Uterus, Qi and Blood Deficiency, Cold Invasion in the Uterus, Residual Heat, Liver and Kidney Deficiency, Damp-Phlegm Accumulation (multiple selection).
  • Pediatric Specific Syndromes (under 18): Food Accumulation, Pediatric Malnutrition, Pediatric Convulsions.
• 4Lifestyle:
  • Physical Activity: Sedentary to elite athlete.
  • Type of Work: Open field.
  • Stress Level: Scale from 1 (Very low) to 5 (Very high).
  • Sleep: Sleep quality (excellent to very poor) and sleep habits (hours, insomnia).
  • Consumption: Alcohol (never to daily), tobacco (yes, no, former smoker), hydration level (liters per day).
• 5Food Preferences and Restrictions:
  • Main Diet: Omnivore, vegetarian, vegan, ketogenic, paleo, gluten/dairy-free (by choice), halal, kosher, pescatarian, flexitarian, other (specify).
  • Foods: Disliked or not consumed, preferred (with examples).
  • Consumption Frequency: Red meat, poultry, fish, dairy products, refined grains, added sugar/sweet products, processed foods (frequency scales).
  • Eating Habits: Number of meals, snacks.
  • Specific Practices: Religious fasting or other practices (e.g. Ramadan, intermittent fasting).
• 6Specific Goals:
  • Weight Goal: Weight loss, maintenance, or weight gain (with target weight in kg if applicable).
  • Other Health/Well-being Goals: Improved digestion, increased energy, reduced fatigue, better concentration, etc.
  • Main Motivation: Why are you looking for a personalized diet?
• 7Additional Information / Notes:
  • Open field to add any information deemed relevant for optimal diet personalization.