mgr Julia Dobosz

Pierwsza wizyta
PL EN

General information

1. General information

(rok-miesiąc-dzień)
(np. 0048100100100)
kg
cm

Daily activity routine

2. Daily activity routine

Sports activity routine

3. Sports activity routine

Other remarks

Diet and lifestyle

4. Diet and lifestyle

Do you add extra sugar?*

How often do you consume alcohol?*

What type of alcohol do you prefer the most?*

How much water do you drink daily?*

How much water do you drink daily?*

Do you often eat out?*

Do you eat yellow cheese, processed cheese, or cream cheese?*

Do you eat products like sausages, hot dogs, pâté, or other similar deli meats?*

What type of bread do you eat most often?*

How often do you eat sea fish?*

Do you use a lot of salt?*

How many main meals do you consume per day?*

Do you often snack between meals?*

How often do you eat sweets?*

During a diet, can you completely give up sweets?*

Do you frequently drink sweet beverages, fruit juices, flavored waters, etc.?*

Your sample day meals

5. Your sample day meals

Create a list of consumed products for at least one selected day. When preparing the list, it is important to remember to record every consumed product, including all liquids (including water). Each entry for a particular day should include the following information:

  • 1. Hour
  • 2. products
  • 3. size/amount of product consumed

The more precisely you specify the composition of the meal, the more accurate the analysis of your previous diet will be. It is very important to specify the size of the product or the number of grams. Each meal should be broken down into individual ingredients. Instead of "Roll with cheese," it is better to write "wheat roll" and "cheddar cheese" (see example below). It is also important not to "improve" the diet but to record everything truthfully.

Here is an example:

  • Meal time 8:00

    • wheat roll, 1 large
    • butter, flat teaspoon
    • cream cheese, 2 large spoons
    • apple, 1 large
    • tea, 1 glass
    • sugar, 2 teaspoons

  • Meal time 8:10

    • water, 0,5l

  • Meal time 9:00

    • Snickers, 1 bar
    • banana, 1 large

  • Meal time 10:30-11:30

    • I did aerobics

  • Meal time 13:00

    • Banana, 1 medium

  • Meal time 14:00

    • pork chop, medium about 150g
    • potatoes, 2 medium pieces
    • butter, 1 teaspoon
    • carrot and white cabbage salad, 1/3 large plate
    • cherry compote, 1 glass

  • Meal time 18:00

    • McDonald's hamburger, two pieces
    • Coca-Cola, 0,5l
    • fries, small

  • Meal time 22:00

    • water, 2 glasses
    • milk chocolate, 5 pieces

Describe your current diet using the form below

Add meal

Diet goal

6. Diet goal

What is the main goal of the program?*

Do you have problems with cholesterol or triglycerides?*

Sugar

mg/dl

Do you have high blood pressure?*

Do you have issues with constipation?*

Describe any other health problems?

List the food products you dislike or are intolerant to

Do you take any dietary supplements? If yes, please specify

Do you take any dietary supplements? If yes, please specify

Other remarks

If you have blood test results that you might want to send, please send them to the email address: julia.dobosz@dobrydietetyk.pl

Specify the hours when you can eat Meals during the day. Breaks between them should not be longer than 4 hours, the first meal should not be eaten later than 2 hours after waking up, and the last 2-3 hours before going to bed. Also indicate which Meals you will eat at home and at what time you will eat lunch Meals.

Przykład w jaki sposób wypełnić formularz

Use the above example, which contains information:

  • Meal will be eaten from Monday to Friday at 8:00, 12:00, 15:00, 18:00, 20:30.
  • Meal will be eaten on Saturday at 8:00, 11:00, 14:00, 17:00, 20:00.
  • Meal will be eaten on Sunday at 9:00, 13:00, 16:00, 19:00.

In the above example, lunches will be eaten as follows:

  • From Monday to Friday at 12:00 and 18:00.
  • On Saturday at 11:00 and 17:00.
  • On Sunday at 13:00.

Preferred meal times

Hour:
Meal eaten at home
Lunch meal
Hour:
Meal eaten at home
Lunch meal
Hour:
Meal eaten at home
Lunch meal
Hour:
Meal eaten at home
Lunch meal
Hour:
Meal eaten at home
Lunch meal
Hour:
Meal eaten at home
Lunch meal

Delivery address

7. Delivery address

I declare that I consent to the processing of my personal data and health data to the extent necessary to create a nutritional program for me and for administrative purposes, in accordance with the Personal Data Protection Act of 29 August 1997 (Journal of Laws of 2002, No. 101, item 926, as amended). At the same time, I declare that the consent does not include the right to process my personal data for purposes other than those indicated in the statement. I also declare that I have been informed of my right to access, modify, and request the permanent deletion of my data from the information system in which they were recorded. Database Administrator: APZ.PL Sp. z o.o., ul. Lisieckiego 13, 63-400 Ostrów Wielkopolski
I declare that I have read and accept regulamin świadczenia usług.

Invoice details

8. Invoice details

POKAŻ