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Welcome to the 5-Week Healthy Keto Challenge
Please fill in the form and complete the payment at the end of the form. We will send you your customised Meal plan along with your Personalised Report within 48 Hours
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1
Name
*
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First Name
Last Name
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2
Sex
*
This field is required.
Male
Female
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3
Select the Body Type that is Closest to Yours
This will help us estimate the fat weight and how much is safe for you to lose
5% - 9%
10% - 14%
15% - 19%
20% - 24%
25% - 29%
30% - 34%
35% - 39%
40%+
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4
Select the Body Type that is Closest to Yours
This will help us estimate the fat weight and how much is safe for you to lose
15% - 19%
20% - 24%
25% - 29%
30% - 34%
35% - 39%
40% - 44%
45% - 50%
50%+
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5
Contact Details
*
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Please enter your email. Preferably Gmail.
Please enter your mobile phone without '0' or country code
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6
City/Country
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
India
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
Profession ?
*
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Choose any one
Business
Sportsperson
Actor/Model
Home Maker
Student
Service
Other
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8
Date of Birth
*
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-
Date
Day
Month
Year
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9
Height
*
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10
Weight
*
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11
Goal Weight
*
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12
What is the level of your Physical Activity?
*
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Choose any one
Sedentary. Typical desk job, little to no exercise.
Lightly active. Walking around a good amount, retail jobs. 1–3 hours per week of light exercise.
Moderately active. 3–5 hours a week, e.g. daily 15 minutes biking and 3 times heavy lifting per week.
Very active. Construction workers, hard exercise 6–7 days per week
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13
Check all applicable
*
This field is required.
I have diagnosed with IBS or GERD
I am Diabetic
I have hormonal issues
I have thyroid issues or concerns
I have/am suffering from depression or anxiety
I have PCOD
I have auto-immune disease
None of the Above
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14
Do have any pre-existing medical condition not covered in previous question?
*
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Please include and list all surgeries as well
YES
NO
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15
List all Medical Conditions in as much detail as possible
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Ok
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16
Do you regularly take any Medication or Supplements ?
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YES
NO
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17
List all Medication and Supplements you take
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18
Medical Conditions Terms & Conditions
*
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Please read the Terms & Conditions VERY Carefully. If you are diabetic Ketogenic Diet is not advisable without proper supervision.
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19
How many meals do you consume?
*
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Your meal plan will be created as per the meals that are selected.
Breakfast
Lunch
Snack
Dinner
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20
Dietary Orientation
*
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Jain
Vegetarian
Eggitarian
Non-Vegetarian
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21
Which of these do you eat?
Egg
Chicken
Mutton
Fish
Shell Fish
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22
Are There Any Specific Days On Which You Do Not Eat Non-Veg?
Choose all applicable
None - I eat Non-Veg on all day
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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23
Are There Any Specific Days On Which You Do Not Eat Egg?
Choose all applicable
None - I eat eggs on all days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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24
Breakfast
Select 1 option
I am comfortable eating eggs everyday
Alternate days eggs & Alternate days Parathas
Alternate days eggs & Alternate days DIY Keto Granola
Alternate days eggs & Alternate days spinach soup with nuts & cheese
I don't like to eat eggs, I'm just okay with eggs if I can't taste them - like in deserts
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25
Select foods that you are allergic to or dislike
Select ingredients ONLY if they are a STRICT no-no for you.
Brocolli
Cauliflower
Nuts (Almonds/Walnuts)
Peanuts
Dairy
Garlic/Onion/Ginger
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26
What would you like to have for breakfast?
You can change this later as well if you like.
Parathas Everyday
Alternate days DIY Keto Granola & Alternate days Spinach soup with Nuts & Cheese
Alternate days Parathas & Alternate days DIY Keto Muesli
Alternate days Parathas & Spinach soup with Nuts & Cheese
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27
Dinner Meal Preference
I'm comfortable having Non-Veg eveyday
I'm comfortable having Non-veg every alternate day and Paneer every alternate day
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28
Do you Drink Tea or Coffee with Milk?
*
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Milk Tea
Milk Coffee
Neither
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29
How many cups do you drink in a day?
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30
Where did you hear about us?
*
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Facebook
Instagram
Online Blogger
Gym Instructor
Newspaper
Friends & Relatives
Nutritionist
Other
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31
Terms & Conditions
*
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Please Read the Terms & Conditions carefully
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32
Money-Back Guarantee
*
This field is required.
I understand and agree that the Money-Back Guarantee is valid only when I follow the diet as per design. This includes posting photos of everything I eat on the Whatsapp group everyday, posting photos of my keto strips everyday and logging in my weight once a week. I understand that by failing to do the above mentioned activities automatically disqualifies my Money-Back Guarantee.
I don't want Money-Back Guarantee
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