*-Required

PROGRAM INVESTMENT - $127


~ STEP 1 - PERSONAL INFO ~
*First Name

*Last Name

*Address

*Phone

*Email

*Primary Physician

*Physician's Phone

*DOB (MM/DD/YYYY)

*Age

*Height

*Weight

*Desired Weight

*Body Fat %

~ STEP 2 - HEALTH HISTORY ~
Check all that apply
Diabetes
Heart Disease
Kidney Disease
Celiac Disease
Stroke (within last 6 Months)
Cancer
Diverticulitis
Osteoarthritis
Eating Disorder
Sleep Apnea
Hypertension
High Cholesterol (>160)
Pregnant/Nursing
Under Age 18
Hypothyroidism

Other (Please Specify):

Please provide details for any condition selected above

Are you currently under a physicians care for any reason?
*Please Select

If YES please describe

Do you currently take medications and/or supplements?
*Please Select

If YES please list

Do you currently smoke?
*Please Select

~ STEP 3 - PHYSICAL ACTIVITY REVIEW ~
My Work/Daily Responsibilities Primarily Involve the Following:
*Please Select
Sitting
Standing
Walking Actively
Heavy Labor

Outside of Normal Work/Daily Responsibilities, My Activity Level Looks Like:
*Please Select
Little or No Exercise
Light Exercise/Sports 1-3 Days/Week
Moderate Exercise/Sports 3-5 Days/Week
Hard Exercise/Sports 6-7 Days/Week
Very Hard Exercise/Sports & Physical Job or 2x Training

~ STEP 4 - EATING HABITS ~
I am most challenged when I am eating at:
*Please Select

I often overeat when I am with:
*Please Select

Record the following amount of beverages you consume per day:
*REGULAR SOFT DRINK

*DIET SOFT DRINK

*COFFEE

*SWEET TEA

*ALCOHOLIC BEVERAGES

*WATER

The meal I tend to skip the most is:
*Please Select

The biggest meal of the day is:
*Please Select

The time I eat and food I eat with that particular time:
*BREAKFAST

*Please list your typical breakfast choices

*LUNCH

*Please list your typical lunch choices

*DINNER

*Please list your typical dinner choices

Do you snack between meals?
*Please Select

*Please list your typical snack choices

My food is usually prepared by:
*Please Select

When salting my food, I salt:
*Please Select

The foods I tend to crave the most are:
*Please Select

When eating the foods I crave, a normal serving:
*Please Select

Below is a list of common food choices. Please go through and check the food items you prefer NOT to have included in your meal plan.
FRUIT
Cantaloupe
Watermelon
Apple
Banana
Orange
Strawberry
Pears
Grapefruit
Grapes
Peach
Pineapple
Unsweetened Fruit

VEGETABLE
Tomato
Broccoli
Zucchini
Mushrooms
Lettuce
Carrots
Cucumber
Cauliflower
Onion
Celery
Spinach
Juice

GRAINS/STARCH VEGETABLES
Rice
Pasta
Noodles
Bagels
Oatmeal
Grits
Potato
Sweet Potato
Corn
Beans
Whole Wheat
Bread
Pretzels
Crackers

MEAT/MEAT SUBSTITUTE
Chicken
Tofu
Fish
Sirloin
Cheese
Lean Roast Beef
Lean Ham
Beans
Eggs
Cold Cereals

DAIRY
Skim Milk
1% Low Fat Cheese
Low Fat Yogurt
Low Fat Cottage Cheese

FAT
Butter
Nuts
Seeds
Salad Dressing
Sour Cream
Cream Cheese

Please check any special dietary needs that you may require:
Select Only If Applies
GLUTEN FREE
VEGETARIAN

If Vegetarian Please Select Type:

Do you have any food allergies?
*Please Select

Please Provide Details

STEP 5 - YOUR GOALS
Number Your Health Goals Below 1-6 (1 Being Most Important)
*Improve My Eating Habits

*Improve My Health Status

*Increase Muscle Mass

*Feel Better About Myself

*Reduce Body Fat

*Have More Energy

Please feel free to provide any additional information you wish to provide:
(Optional)

PLEASE CLICK SUBMIT TO COMPLETE YOUR EVALUATION
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