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Nutrition Questionnaire

ABS ARE MADE IN THE KITCHEN.

Order your customized meal plan for a once of fee of R400 from our registered nutritionist at SWAN Nutrition. Fees will be collected with your next monthly debit.

Personal Details - Step 1 of 4

Name *

First

Last

Occupation *

Email *

Goal: (a short paragraph on what you would like to achieve)

Gender *

Male
Female

Age *

Weight *

Your Height (eg 1.63m) *

My Hip Circumference is (cm) *

Then measure the distance around the largest part of your hips — the widest part of your buttocks. This is your hip circumference.

My Waist Circumference is (cm) *

"Stand up straight and breathe out. Use a tape measure to check the distance around the smallest part of your waist, just above your belly button. This is your waist circumference."

Body Type *

skinny
athletic
a few extra kg

Do you suffer from High Cholesterol? *

Yes
No

Do you have Diabetes Mellitus? *

Yes
No

Do you have hight Blood Pressure? *

Yes
No

Are you currently experiencing any of the following? (tick if applicable) *

Diarrhea
Constipation
Reflux/ Heart Burn
IBS
Fatigue
None

Are you currently being treated for any medical condition? *

Yes
No

Please explain about the treament being received

Are you currently taking any medication? *

Yes
No

Are you taking any food and/or vitamin and mineral supplements? *

Yes
No

Do you have any food allergies? *

Yes
No

Please list the current medication you taking

List food and/or vitamin and mineral supplements you are currently taking *

Tell us about your food allergies

Are you currently following any specific diets or dietary habbits? *

Yes
No

Tell us about your current diets or dietary habbits *

Do you consume alcholic beverages? *

Yes
No

How many caffeinated beverages (Coffee, Tee, Energy Drinks, Soda etc.) do you consume in a day? *

How many alcoholic beverages do you consume in a week? *

Give a quick idea of what a typical day's diet (food and drink) looks like: *

Fee Agreement *

You hereby agree that Fight Club South Africa will load a once off cost of R400 on your next available debit order

Fight Club SA will empower you with the necessary skills to achieve various fitness goals whilst training in the sport of boxing. Our approach is focused on understanding and developing the skill of boxing as a means of increasing core strength, losing weight, learning self-discipline and relieving stress. This is exactly why we are a Reebok Brand Partner.

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