I consent to receiving communication from BBHC as part of the introduction to the Best Body Health Coach program, as well as the occasional marketing email. I also understand that this survey is in no way designed to diagnose, treat or otherwise solve medical issues. It is simply there to give our coaches an idea of where to start with your personalised health program.

First Name *

Last Name *

Email *

Date of birth *

Gender *

Male

Female

City *

Country *

Phone *

Who referred you? If no one simply state none. *

What is your goal weight? *

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Have you had any major health issues? *

Yes

No

Are you currently on any kind of acute/chronic medication? *

Yes

No

Do you have a history of street drugs/steroid use? *

Yes

No

Do you have a history of heavy alcohol use? *

Yes

No

Do you have any allergies that you know of? *

Yes

No

Have you been diagnosed with Diabetes Type 1? *

Yes

No

Have you been diagnosed with Diabetes Type 2 or similar? *

Yes

No

Do you crave sweets, candy, bread, and pasta? *

Yes

No

Do you crave chocolate or salty snacks? *

Yes

No

Do you crave potato chips or food that is deep-fried? *

Yes

No

Do you crave dairy products such as ice cream, cream cheese, sour cream, or milk? *

Yes

No

Are you prone to feelings of depression or hopelessness? *

Yes

No

Are you someone who often worries or gets anxious and nervous? *

Yes

No

Are you snappy, irritated, and moody in the morning? *

Yes

No

[Simply click "Next" if you are male]

Are you moody or irritable around/during your menstrual cycle? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you feel better when you eat fruits and berries? *

Yes

No

Do you have to have coffee or other stimulants in order to wake up? *

Yes

No

Do you sometimes have a feeling of tightness over your right lower-stomach area or rib cage? *

Yes

No

[Simply click "Next" if you are male]

Do you get constipated during your menstrual cycle? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you have vertical ridges on your nails and are they brittle? *

Yes

No

[Simply click "Next if you are male]

Do you as a female, have facial hair?

Yes

No

Do you have pain or stiffness in your right shoulder/blade area? *

Yes

No

Do you have pain in your lower-back or hip area? *

Yes

No

Do you have evenly distributed fat on your body? *

Yes

No

Do you have a pendulous belly (saggy and hangs over the belt)? *

Yes

No

Do you have a hard protruding potbelly? *

Yes

No

Do you have fat distributed around your thighs, hips and lower stomach area? *

Yes

No

Do you have dry skin especially around your hands and elbows or other areas? *

Yes

No

Do you have swelling around your ankles? *

Yes

No

Do you have dandruff or flaky skin in your eyebrows? *

Yes

No

[Simply click "Next" if you are male]

Do you have hair loss that occurs during your menstrual cycle? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you have indentations made by your teeth on each side of your tongue? *

Yes

No

Do you have difficulty getting up from a seated position due to weakening of your thigh muscles? *

Yes

No

Do you have urine that is dark yellow in colour? *

Yes

No

Do you have occasional hot flashes? *

Yes

No

Do you have bald patches on the outer third of your eyebrows? *

Yes

No

Do you get dizzy when you stand up too quickly? *

Yes

No

Do you get hot or swollen feet? *

Yes

No

[Simply click "Next" if you are male]

Do you experience brain fog during your menstrual cycle? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you get cold at night and must sleep with socks on? *

Yes

No

Do you experience chronic inflammation in your body? *

Yes

No

Do you experience headaches or a heavy head in the morning? *

Yes

No

[Simply click "Next" if you are male]

Do you experience excessive bleeding when menstruating? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you experience puffiness around your eyes? *

Yes

No

Do you get unusually out of breath while climbing stairs? *

Yes

No

Do you have any psoriasis, eczema, brown spots, or other skin problems? *

Yes

No

Do you have low libido? *

Yes

No

Do you have flabby skin under your arms? *

Yes

No

Do you experience twitching under or on top of your left eyelid? *

Yes

No

Do you feel more awake at night and see yourself not as a morning person? *

Yes

No

[Simply click "Next" if you are male]

Do you gain weight one week before your menstrual period? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

Do you experience hair loss or have dry hair? *

Yes

No

Do you find yourself waking up in the middle of the night at 2am or 3am? *

Yes

No

Do you have a white film on your tongue and/or a deep split down the centre of it? *

Yes

No

Do you have a small upper body, disproportionate to your larger lower body? *

Yes

No

Do you lose the curls in your hair after using a curling iron? *

Yes

No

Do you get cramps in your calf muscles at night? *

Yes

No

Do you get itchy skin at night? *

Yes

No

Do you feel you retain water at certain times of the month? *

Yes

No

Do you get very tired in the early evening as opposed to being more awake in the early morning? *

Yes

No

Do you experience your bladder to be more active at night than during the day? *

Yes

No

Do you find that the whites of your eyes have a yellowish colour to them? *

Yes

No

[Simply click "Next" if you are male]

Do you have or have you had ovarian or breast cysts?

Yes

No

Do you lack vitality and that get-up-and-go feeling? *

Yes

No

Do you have bursitis, tendonitis, kidney stones, heel spurs, early cataracts or other calcium issues? *

Yes

No

Do you experience grouchiness when you are hungry? *

Yes

No

[Simply click "Next" if you are male]

Do you find it or have found it difficult to lose weight after pregnancy?

Yes

No

Do you or have you taken part in low-calorie diets? *

Yes

No

Do you become easily irritated and on edge, and can't handle stressful situations? *

Yes

No

Do you experience stiffness and pain mostly in the right shoulder and right side of the neck? *

Yes

No

[Simply click "Next" if you are male]

Do you when on your menstrual cycle, have pain and stiffness in your one knee? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle)

Yes

No

In order to accurately assess your body type, etc., our coaches will need a few photos from you. These photos are kept securely on our server and will be deleted after assessment.

If you are unable to provide these now, you will have another chance to send them to your assessing coach during your interview.

Please upload three photos of yourself:

One full photo of your body taken from the front.
One full photo of your body take from the side.
One photo of just your face, with your tongue out.

Photo Upload:

Are you human?

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