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Home Surrogate Intake Form

Surrogate Intake Form

Surrogate Intake Form

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Email

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Personal Information

Full Name*

Date of Birth*

MM slash DD slash YYYY

Age*

Address*

Zip/Postal Code*

City*

State*

Email*

Phone*

Occupation*

Current Weight (lbs)*

Height (cm)*

Referred by*

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Activity Level

Sedentary

Sedentary

(little or no exercise, desk or bed ridden)

Very Active

Very Active

hard exercise – sports 6-7 days per week

Light Activity

Light Activity

(little or no exercise, desk or bed ridden)

Extra Active

Extra Active

hard daily exercise – sports and physical job

Moderate Activity

Moderate Activity

hard daily exercise – sports and physical job

Food Component I Avoid

Amines

Amines

Refined sugars

Refined sugars

Non-food Items (synthetics)

Non-food Items (synthetics)

Caffeine

Caffeine

Harmful Fats

Harmful Fats

Dairy (casein & lactose)

Dairy (casein & lactose)

Eggs

Eggs

Alcohol

Alcohol

Fluoride/Chlorine

Fluoride/Chlorine

Shellfish

Shellfish

Yeast

Yeast

Gluten & Gliadin

Gluten & Gliadin

Soy

Soy

Sulfites

Sulfites

Citrus Fruits

Citrus Fruits

Salicylates

Salicylates

Theobromine

Theobromine

Carcinogens & Toxins

Carcinogens & Toxins

Glutamates

Glutamates

Pesticides

Pesticides

(for organic diets)

Mercury Contaminated Food

Mercury Contaminated Food

Ethnic & Vegetarian Intolerances

check to remove from diet

Red Meat

Red Meat

Poultry

Poultry

Dairy Foods

Dairy Foods

Non-Hindu Foods

Non-Hindu Foods

Eggs and Egg Products

Eggs and Egg Products

Non-Kosher Foods

Non-Kosher Foods

Fish and Seafood

Fish and Seafood

non-Muslim Foods

non-Muslim Foods

I have cravings

I have cravings

I have specific carvings

I have specific carvings

When do you crave that?*

How often?*

Nutrition

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Breakfast

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Snacks before Lunch

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Lunch

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Snack before dinner

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Dinner

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Snack at night (desert)

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Water (ounces)

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Total Calories: Even if you have to guess

Your Idea of a “GOOD” Day

Your Idea of a “BAD” Day

A Typical Day

Exercise

Exercise Name

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Your Idea of a “GOOD” Day

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Your Idea of a “BAD” Day

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A Typical Day

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CONTACT

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Location

7220 Avenida Encinas,
Suite 110-B
Carlsbad, CA 92011

Working hours

Office hours :

Weekdays 8:00 am to 5:00 pm

Saturday 8:00 am to 1:00 pm

Coaching Hours:

Weekdays 6:00 am to 7:00 pm

Saturday 8:00 am to 2:00 pm

Contacts

Office/Scheduling: 858 228 3644

Fax: 858-228-3641

E-mail: info@biointelligentwellness.com

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Appointment Form

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  Office Hours : Monday — Thursday 9:30am to 6:00pm
  Friday 9:30am to 2:00pm
  
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Seminar Virtual

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Ideal protein game day recipes cookbook

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BioIntelligent Wellness’ Ideal Protein Cookbook

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