Registration

    My Personal Details
    mf
    yesno
    no


    My General Health and Food Preferences

    I DO NOT HAVE ANY medical conditions, allergies, etc.

    Cardiac InsufficiencyJoint PainKidney ComplaintsAsthmaThyroid HyperfunctionThyroid HypofunctionVertigo / DizzinessSkin disordersMigraineDiabetesHigh Blood PressureGluten intolerance / AllergyLactose intoleranceOther, e.g. Sleep Disturbance, Depression, Digestive Issues:

    I AM NOT CURRENTLY TAKING ANY medication, hormones, etc.

    CholesterinBlood lipidsUric acidDiabetesThyroidHeartOther, e.g. Antipsychotics, Contraceptive / Hormone replacement:

    I eat EVERYTHING (no food allergies?)

    (Select 4 max)

    I RARELY eat: MeatPoultryFishCheese

    I NEVER eat: MeatPoultryFishCheeseCow’s MilkNatural YoghurtGoat’s Milk/YoghurtSheep’s Milk/YoghurtSeafoodSoya ProductsPorkOther:


    My Goal

    To lose weightTo keep the same weight

    Language nutrition plan?
    EnglishGermanFrenchItalian

    Type of support
    ONLINEON-SITE (in one of our practices)

    Package?
    ONLINE
    Where?
    ZurichBasleLucerneHerisauBenglen (Fällanden)

    Package?
    BASICSTANDARDPREMIUM

    Single Person or Group?
    Single PersonGroup of 2Group of 3

    First name, surname of 2nd group member
    First name, surname of 2nd group member
    First name, surname of 3rd group member


    Miscellaneous

    How did you hear about us?
    InternetCustomer stopperCarmela PlacaRecommendation

    Newsletter?
    I would like to regularly receive the health newsletter.

    Comments

    I agree that my data can be saved for the purpose of creating my plan. Other than the necessary data entries for diagnosis and treatment (establishing blood values, plan preparation) Metabolic Balance GmbH undertakes not to pass on the data to uninvolved third parties.

    Metabolic Balance can not provide a nutrition plan for pregnant women, nursing mothers or patients with severe renal or hepatic insufficiency.

    Registration for the Metabolic Balance programme is definitive and binding. The participant undertakes to assume any costs incurred by an annulation (for example, drawing up a plan).