Femly — FDF — Final Diet Fix Intake Form
Femly — FDF — Final Diet Fix
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Section 1 of 10 0%
🌿 Take your time with this form Your detailed assessment is very important for us to support your health effectively — every answer helps us personalise your care.
Section 1 of 10
Contact & Identity
Your basic details help us set up your profile.
Please enter your full name
Please enter a valid email
Please enter your phone number
Section 2 of 10
About You
Help us personalise your program to your body.
Please select your complete date of birth
Please select your gender
Please select your height
in kg
Please enter your current weight
in kg
Please enter your target weight
Please select your profession
Section 3 of 10
Medical & Health
This helps your dietitian personalise your plan safely.
Please select at least one option
Common: Metformin / Thyroid meds / BP meds / Vitamins / Contraceptives / None
Please select at least one option
Please select at least one option
Please select an option
🔬 Required for FDF — Upload your most recent blood reports (CBC, thyroid, lipid panel, etc.)
🔬
Drag & drop or browse files
PDF, JPG, PNG — max 10 MB each
Please upload at least one lab report
Section 4 of 10
Diet & Food Preferences
We'll build your plan around foods you actually enjoy.
Please select your diet type
Please select at least one cuisine
Please select an option
Please select an option
Please select at least one beverage
6 glasses
Please select an option
Section 5 of 10
Goals & Motivation
Understanding your why helps us keep you on track.
Please select at least one goal
Please select at least one option
Please select an option
Please select at least one option
Please select an option
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Please select at least one option
Section 6 of 10 — FDF
Your Diet History
Understanding what hasn't worked before helps us make this time different.
Please select an option
Section 7 of 10
Daily Activity & Sleep
Sleep and daily patterns directly affect weight and hormones.
Please select an option
Please select an option
🌅 Morning
☀️ Afternoon
🌆 Evening
🌙 Night
Section 8 of 10
Mental Well-being
A safe, private space — handled only by our psychologist.
🔒 Confidential. Your answers here are NOT shared with dietitians or coaches. Only our licensed psychologist has access to this section.
As part of your holistic Femly program, you will be receiving Mental Health & Wellness sessions — led by our licensed psychologist. These sessions are a safe, private space for you to grow from the inside out.
Please select an option
Please select an option
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Please select an option
Please rate your mood
Please rate your stress level
Section 9 of 10
Workout & Physical Activity
For your workout coach to design the right sessions.
Diet manages calorie intake, but physical activity is what makes results sustainable. Your workout coach will use this to match sessions to your current level and goals.
Please select an option
Please select an option
Please select an option
🏋️ Workout
🧘 Yoga
Please select at least one time slot
Section 10 of 10
Progress Photos & Closing
Photos help us track your progress accurately.
📸 Photo Instructions

✅ Stand against a clear background / wall
✅ Wear a fitted T-shirt and pyjama / shorts
✅ Stand straight with arms slightly away from body
✅ Take in good natural light
❌ Avoid black clothing
❌ No mirror selfies

All photos are stored securely and visible only to your assigned dietitian and coach.
🧍
Front
Face the camera directly
Please upload your front view photo
🚶
Back
Turn fully away from camera
Please upload your back view photo
👤
Left Side
Turn left side to camera
Please upload your left side photo
👤
Right Side
Turn right side to camera
Please upload your right side photo
Please select how you heard about us
Your data is encrypted and handled in accordance with Femly's privacy policy.
🌸
You're all set!

Your health profile has been submitted to the Femly team.

Your assigned health consultant will reach out within 24 hours to schedule your first call.

Thank you for trusting Femly with your health journey.

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