HEALTH QUESTIONNAIRES

Postpartum Slimdown Questionnaire

* Indicates required field

Name: *

First

Last

Email: *

Phone Number: *

Age: *

Height: *

Current Weight: *

Pre-Pregnancy Weight: *

Have you lost a significant amount of weight in the last 6 months? *

Yes No

Are you pregnant? *

Yes No

Are you breastfeeding? *

Yes No

If applicable, please specify when you stopped breastfeeding: *

Are you on any anticoagulant or anti platelet medications? *

Yes No I'm not sure

If yes, please list: *

List of current medications and/or supplements: *

List any preexisting health conditions (i.e. anxiety, depression, breast cancer, insomnia, etc.): *

List any allergies, sensitivities or intolerances to foods and/or medications: *

What are your weight loss goals? Be specific! *

Anything else we should know? *

Please select how you would like to be communicated with: *

Text Email Phone

By submitting this form, I agree and understand that this program is a very low calorie protein diet. On this program, you may experience the following symptoms including fatigue, headache, nausea and diarrhea among other symptoms. If symptoms persist, please contact a healthcare professional. I agree to purchase and follow the instructions detailed in the "7-Day Postpartum Slimdown" eBook, and to follow the program under medical supervision or under the supervision of a Postpartum Slimdown practitioner. I agree that this product and/or program is not intended by infants, children or pregnant or nursing women. I understand that some of these products may expose me to naturally-occurring elements known to the State of California to cause birth defects or other reproductive harm. For more information, go to www.P65Warnings.ca.gov. I agree that I do not have any preexisting health conditions that has not been approved by a Postpartum Slimdown practitioner prior to starting the program. I certify that the aforementioned information provided is accurate and true. Lastly, I release CATE AND ILA, LLC from any illness, injury or harm that results from participating in the program and consuming the recommended products. *

I AGREE

Submit

POSTPARTUM SLIMDOWN​HEALTH QUESTIONNAIREPlease fill out prior to beginning the program.

Postpartum Slimdown Questionnaire

POSTPARTUM SLIMDOWN
HEALTH QUESTIONNAIRE
Please fill out prior to beginning the program.