Personal Profile

This profile questionnaire is to be used in conjunction with the various meal plans we offer. If you have submitted your payment, please answer the following questions, so you are able to customize your plan. We will help take the guess work out of many carbohydrates, proteins and fat calories you should be consuming to meet your goals. Once your payment has been processed your meal plan with instruction will be Emailed to you.

The information you provide in your questionnaire form will be kept confidential

Select Your Meal Plan

First Name

Last Name

Date of Birth  (M/D/Y)              Age

Address

City

State            Zip Code


Home Telephone

Cellular Telephone

Work Telephone

Email

Gender

Male Female Pregnant?   months

Height



Present weight

lbs

Goal weight

lbs

Body fat %

How taken:

Body build



Place your thumb and middle finger around your wrist.

Small = fingers overlap.   Medium = fingers touch.
Large = fingers don't touch

Lifestyle / Profession

Rate your overall activity level of your profession:

Your goal

Body type

Which one BEST describes you:

Health & Medical condition

                                                     If other please explain:


Weekly exercise routine

Please include activity, days and times.

Foods you like

Foods you dislike

Have you ever been placed on any type of weight management program in the past:
NO   YES, please explain why and results:

Any Additional information you would like to add:

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