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Please confirm your order
*
1x personalized nutrition plan online and 1 bonus online consultations
110 € (830 kn)
Name and last name
*
First
Last
Email
*
Phone
*
partner ID
Body weight
70
kg
Height
173
cm
Age
18
yrs
Sex
*
female ♀
male ♂
Body fat
Waist and hip circumference
Target body weight
Exercise / training
*
no exercise at all
no exercise, walking at least 1h/day
1-2 x week
3-4 x week
3-4 x week and active lifestyle
afternoon/evening exercise after work
pro sport 4-5 trainings + competition
Describe your activity level?
*
1,2 sedentary, very little activity
1,4 sedentary, office job, some activity
1,5 sedentary, little activity, working light
1,6 moderate activity sitting/standing/walking job
1,8 active, in motion /standing/walking day
2,0 physical work, active sports
2,4 hard physical labour, pro-sport
celery
Foods that are NOT included in your diet (allergies/intolernce)
I eat all foods
meat
pork
chicken
fish
shellfish and marine products
mushrooms
milk
dairy products, cheese
peanuts
soy
peas
lentils/pulses
nuts
citruses
salad
eggs
sesame
yeast
wheat
gluten
rice
strawberries
garlic
onion
tomato
pickled food
peppers
spicy food
sour foods
histamine
(you may use multiple choices)
something else:
Do you drink caffeine beverages?
*
coffee
green or black tea
energy drinks
cola soda drinks
a combination of above listed
How many cups of caffeine beverages do you take daily? (incl. coffee, green/black tea/energy drinks/cola drinks)
none
1 cup (morning or afternoon)
2-3 cups a day
3-5 cups a day
> 5 cups a day
Describe your typical daily diet:
*
I eat at home
carry home prepared meals
restaurant / cantina
meal delivery or fast food
supermarket or street food
snacking, no regular daily meals
sandwiches
coffee and sweets
special diet
(you may use multiple choices)
I am on a special diet - please provide more detail here
describe a special diet you may adhere
Check your daily meal times
*
early breakfast 04-06
breakfast 07-09
morning snack 10-12
lunch 12-15
afternoon snack 15-17
evening dinner 17-19
late dinner 20-22
night meal 23-03
constant snacking during the day
(you may use multiple choices)
Describe your meals during the past (24 h recall diet)
*
BREAKFAST
*
your typical breakfast choices
LUNCH
*
BETWEEN MEAL SNACKS
*
EVENING DINNER
*
How much time can you afford for meal preparation?
*
No time at all - eating out or delivery
I have time to prepare all the meals
Part self-prepared, part delivery or restaurant
Do you take food supplements?
*
Proteins
Magnesium
Multivitamin
Other supplements
How often do you have fish and marine products in your diet?
*
never
monthly
once a week
2 or more times a week
How often do you have dairy products in your diet?
*
never
1-3 x weekly
1 x every day
2 or more times a day
How often do you have fruit and fruit products in your diet??
*
never
1-3 x week
1 x every day
2 or more servings a day
How often do you have vegetables and veggie products in your diet?
*
never
1-3 x weekly
1 x every day
2 or more a day
How often do you meat have products in your diet?
*
never
1-3 x weekly
1 x every day
2 or more servings a day
How often do you have bread, pasta, grains, potato products in your diet?
*
never
1-3 x weekly
1 x every day
2 or more servings a day
with every meal
How often do you have nuts and seeds in your diet?
*
never
1-3 x week
1 x every day
2 or more servings a day
How often do you have sweet and salty snacks and conditory products in your diet?
*
never
1-3 x week
1 x every day
2 or more servings a day
If you would like to add more info about your diet, please write here:
GDPR
*
I hereby confirm the use of my personal data provided in this questionary for the purpose of:
In accordance with the provisions of the General Data Protection Regulation - GDPR, I agree that NUTRISKOP, a nutrition company, may use my personal data for the purpose of creating a nutrition programs and conducting online nutrition counseling. I understand and accept that NUTRISKOP is a data user and will use my personal data for the above purpose and I agree to the following:
1. The NUTRISCOPE shall use the following data for the above purpose of developing a nutrition plan, menu or nutrition consultation:
• Name and surname; • E-mail address; • Phone number • Height • Age • Gender • Body weight • Body Fat content • Waist circumference
2. NUTRISKOP will store my contact details in their database in case they need to contact me for the above purpose.
3. I have the right to withdraw my consent at any time. In this case, the NUTRISCOPE will remove the data from the Nutriscope website within a maximum of one week.
OPTIONAL - Would you like to receive a monthly food and nutrition NU3SKOP newsletter to your inbox?
sure, I'm in!
no, thank you
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