Give Us the Scoop… Foodtrainers Fix Form Name(Required) First Last Preferred email address for Fix Communications:(Required) Where are you located:(Required) City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) MM slash DD slash YYYY Let’s Get Fixing!What prompted you to sign up for this New Year's Fix?(Required) What are your goals for this week? (We aren't against vanity!)(Required)Any calendar goal on the horizon that you are using as motivation (big birthday, wedding, new job or new chapter)?(Required) Any habits you wish to break?(Required) Any rituals you wish to add?(Required) How do you feel going into the Fix? And describe how do you would like to feel at the end of the week?(Required)How would those close to you describe you?(Required) Do you have any challenges that may interfere with this week? This could mean anything from balancing a busy work week to overcoming a specific thought pattern.(Required) If new to Foodtrainers, how did you hear about the program?(Required) Background basics:Please list current medications you are taking, include any type of hormones, over the counter meds (for reflux, sleep, allergies or anything else), etc.(Required)Please list current vitamins and supplements you take regularly including brand and dosage:(Required)Any recent medical issues, conditions, surgeries, or injuries?(Required) Any history of eating disorders or disordered eating?(Required) If you have recent bloodwork, anything to note? What were your Vit D & A1C levels? Even if you were told they were normal, we'd love to know the exact numbers if you have them.(Required) Tell us about your sleep habits. How is your sleep quality, and how many hours do you typically get a night?(Required) Do you live on your own or with others?(Required) Are you currently working? If yes, from home or in the office?(Required) On a scale of 1-10 how content are you with your physique?(Required) Current weight, if you're a weigher? And if you're looking to lose weight, what is your goal weight? Food StuffFill us in on your tendencies.Any food allergies, or foods that you don't eat for medical, religious, or personal reasons?(Required) How would you describe your 2022 eating habits?(Required)Number of alcoholic drinks per week:(Required) Number of meals per week containing carbs:(Required) Time you tend to "close the kitchen" or finish your food day:(Required) How often do you cook weekly?(Required) List any foods that are kryptonite for you (food you tend to overeat):(Required) What do you feel are your Achilles heels when it comes to nutrition?(Required) How do you decrease stress?(Required) Do you follow any specific dietary approach (gluten free, paleo, keto, low carb etc.)?(Required) Any other programs, cleanses, retreats, or regimes you’ve participated in or experimented with? What worked or didn't work?(Required)If you'd like, upload a picture you love of yourself. It doesn't have to be recent. We'd just like to put a lovely face to your name.Max. file size: 32 MB.Waiver & ConsentPlease write your full name as your "electronic signature".Electronic Signature (Full Name)(Required) I hereby engage the services of FOODTRAINERS-HL, LLC for the purpose of performing diet counseling and have been fully advised of all the consequences of the diet counseling. The undersigned is fully aware of the consequences of diet counseling and knowingly and voluntarily approves and accepts the risk thereof. I understand that there is no guarantee that said diet counseling shall prove effective in my case. Not withstanding the foregoing, the undersigned consents to undergo said diet counseling and hereby releases FOODTRAINERS-HL, LLC, its agents or employees from any and all liability as a result of any adverse consequences of the diet counseling. I further state that I have no medical or physical disability or condition, which militate against undergoing such counseling. Δ
