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Elijah Krings Precision Health Coaching Application Form

First Name

*

Last Name

*

Age

*

Country

*

Email Address

*

Phone Number

*

Current Health Symptoms

*

You got any of the following medical diagnosed conditions?

*

Cancer

Liver Disease

Kidney Disease

Eating Disorders (e.g. Anorexia)

Severe mental illness (e.g. Bipolar Disorder, TRD,...)

None

Are you either pregnant or currently breastfeeding?

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Yes

No

Dietary Preferences

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Plant-based / Vegan

Keto / Low-carb

Balanced / Omnivore

How would rate your willingness to change your health?

*

0

1

2

3

4

5

6

7

8

9

10

The coaching offered will cost 1500 EUR. Which fits your best?

*

Ready to invest in your health now

Not Right now