Blood Work Consultation

You are about to begin your VIP Blood work online consultation with Jake

I am diving in to understand your current diet, exercise, and most importantly GOALS.

First Name *

Last Name *

Email *

Phone *

Age *

Gender *

Male
Female
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Height *

Weight *

Country *

IF YOU DON'T MEASURE IT YOU CAN'T TRACK IT!

Photos showcase a better all-round understanding and starting point for us to design a plan best suited for you. We will use these photos throughout your journey to track your performance and results

Please upload your FRONT photo *

Please upload your BACK photo *

Is this your first time working with us? If yes, what was the last JCN plan you completed and how long ago? *

MEDICATION, ILLNESS, INTOLERANACES & ALLERGIES

We need to dive deep into your current health so we can know all the factors that contribute to your diet. Remember I the terms and conditions we do recommend having a medical checkup. Whether you choose to do so or not is your decision.

Do any of the following apply to you? *

Pregnant
Breast feeding
None of the following
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How long have you been breastfeeding for? *

Are you allergic or intolerant to any foods? *

Yes
No
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Please explain the intolerance or allergy and its affects

Are you taking any medication or suffer from any illnesses? *

Yes
No
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Please explain medication or illness

Have you ever experienced or currently have an eating disorder? *

Yes
In the past, yes
No
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Please describe this in further detail:

Do you have a menstrual cycle? *

Yes
No
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How long is your cycle?

How long since your last cycle?

Are you on any contraception? *

Yes
No
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Are you using or have used any PED? *

Yes
No
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DAILY & PHYSICAL ACTIVITY

We need to understand what type of physical activity you are currently doing or able to get into your day to help us build a plan to achieve your goal.

Explain your current exercise regime; Frequency, time of day, duration and type of training/splits. *

CURRENT DIET & HABITS

Be honest and let us know everything! Foods you like, dislike, current habits and anything else we should know. The more information the better we can work with to create the best plan for you.

What is your current diet, list calories and macros if tracking your food? *

Please write down everything you eat and drink including the time and quantities. Do not try to change your eating habits during the Three Day Food Log. *

What are you hoping to achieve with this service? *

Please list any other relevant information for your blood work review

Please tick to agree you understand you will also require to pay for your own blood work on top of this review

When submitted your form, you will then be directed to book your initial consultation with Jake to review your consultation form and give you some more details on what will be needed from you to complete the analyst.