Give Us the Scoop… Foodtrainers Fix Form Name(Required) First Last Preferred email address for Fix Communications:(Required) Mailing address for any Fix products you order:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 the Foodtrainers' Fix? Any milestones on the horizon that you are using as a goal (big birthday, wedding, new job or new chapters)? What are your goals for this week? (We aren't against vanity!) Any habits you wish to break? Any rituals or habits you want to add? How would those close to you describe you? 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. If new to Foodtrainers, how did you hear about the program? Background basics:Current medications, vitamins, supplements: please list the ones you take regularly including brand and dosage, and include any type of hormones, over the counter meds (for reflux, sleep, allergies or anything else), etc.Any recent medical issues, conditions, or injuries? Any history of eating disorders or disordered eating? 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. Tell us about your sleep habits. How is your sleep quality, and how many hours do you typically get a night? Do you live on your own or with others? Are you currently working? If yes, from home or in the office? On a scale of 1-10 how content are you with your physique? Current weight, if you're a weigher? And if you're looking to lose weight, 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? How would you describe your Covid eating?How often do you cook weekly? List any foods that are kryptonite for you (food you tend to overeat): What do you feel are your Achilles heels when it comes to nutrition? How do you destress? What's bringing you joy during this uncertain time? 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
