Weight loss

Looking for dietary advice?

The NHCO Nutrition® Laboratories invites
you to fill out this form in order to bring
to you personalized recommendations for
your current program.

*Sex : FM

*Age

*Height

*Weight

*Waist size

*Hip size

*Physical activity:

Do you engage in fitness activities on a regular basis?
YesNo

If yes, how often?
<1 time a week>3 times a week

*Diet:

Three balanced meals per day
YesNo

Meals on-the-go >3 times a week
YesNo

Do you have a balanced breakfast?
YesNo

Diet rich in fats
YesNo

Diet rich in sugar
YesNo

Regular snacks between meals
MorningAfternoonAfter dinnerNever

Your objective:

Lose weight
YesNo

If yes
Between 1 to 5kg (1 to 10lbs)More than 5kg (10lbs)

Eliminate cellulite
YesNo

Target unwanted curves
YesNo

You can select more than one
BellyeHipsButtocksLegArm

*Are you currently taking food supplements
YesNo

If yes, which one(s)?

*Are you currently undergoing a medical treatment?
YesNo

If yes, which one(s)?

*Are you prone to allergies?
YesNo

Si oui, précisez :

*Are you intolerant to any foods?
YesNo

If yes, please specify

*Civility : MrsMsMr

*Last Name - First Name

Phone number

*Email

Message

*I wish to be kept informed of the new products from NHCO Nutrition® Laboratories YesNo

How did you hear about the NHCO Nutrition® Laboratories?
Pharmacy ConsultingPress, internet or social networksMedical prescription of a health professionalWord-of-mouth

Other

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