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Barbara H. Colby NSCA-CPT Advocare Independent Distributor Wellness Consultant #0002614 E-mail: bcolbynsca@aol.com Phone: (561) 756-1290 Follow us on Facebook Click for a FREE Nutritional Profile So that I may evaluate your current nutritional situation, please complete the form below. This information will help me to design and suggest a program to fit your individual needs. All information is kept strictly confidential. Your Name: Address: City/State/ZIP: Home Phone: Work Phone: Cell or Pager: E-mail: Best time and way to reach you: What is your gender? Male Female What is your age? Years Are you pregnant or nursing? Yes No List all supplements and medicines that you are currently taking. What do you eat for breakfast? Do you do physical exercise during the week such as jogging, walking, biking, etc.? Yes No Do you have any medical conditions, injuries or limitations? If so, what are they? Yes No Do you retain water? Yes No Do you ever experience indigestion? Yes No Are there foods that upset your stomach or that you are allergic to? If so, what are they? Yes No VERY IMPORTANT, so please be honest. Which best describes your frequency of bowel movements? Less than once a week Weekly Daily Every time I eat More often than every time I eat Do you drink coffee or soft drinks? If so, how many per day? Yes per day No How much water do you drink per day (glasses/ounces)? Check which habits you think caused your weight gain: Overeating Late meals Too many sweets or carbohydrates Junk food Too busy to eat right How many pounds or sizes do you want to lose? Pounds: Sizes: Are you willing to commit to your program for at least 90 days? Yes No How did you find our Web site? How do you wish to purchase products? Retail Wholesale Thank you! Barbara will contact you shortly.

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Barbara H. Colby NSCA-CPT
Advocare Independent Distributor, #0002614
Family Fitness & Nutrition

(561) 756-1290 | bcolbynsca@aol.com

www.Advofitforyou.com
www.FitForYou.biz

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