Consultation Questionnaire

FORM

BTMe Consultation Questionnaire

Name

First

Last

Type of Consult

Email address of participant:

Time Zone

Date of Birth

Time of Birth

Gender

Occupation

Weight

Choose your measurement of weight:

Height

Primary Goal of Consult

Problem List (current or previous resolved diagnosises - from Eastern or Western Practioners):

Symptom History

Physicians Notes

How Did You Find Us?

Select your Body Type

Please specify the course(s) you took below.

Navigating Nutrition with the Body Type System™ + Type Me Community

Harmonizing Your Training with the Body Type System™

In the box below, please summarize and describe your experience from days 1-10 of your subscription program

In the box below, please summarize and describe your experience from days 11-20 of your subscription program

In the box below, please summarize and describe your experience from days 21-30 of your subscription program

In the box below, please summarize and describe your experience from days 31-40 of your subscription program

In the box below, please summarize and describe your experience from days 41-50 of your subscription program

In the box below, please summarize and describe your experience from days 51-60 of your subscription program

In the box below, please summarize and describe your experience from days 61-70 of your subscription program

In the box below, please summarize and describe your experience from days 71-80 of your subscription program

In the box below, please summarize and describe your experience from days 81-90 of your subscription program

In the box below, please summarize and describe your experience from days 91-100 of your subscription program

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