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Your Customized Meal Plan
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Your Customized Meal Plan
Your Contact Details
Name
First
Last
E-mail
*
Phone:
Area Code
-
Phone Number
Zip:
About You
Past medical history:
What are your health goals? Check all that apply.
Weight Loss
Weight Management
Post Bariatric Surgery
Weight Gain
Get Stronger
Control Blood Sugars
More Energy
Regular Bowels
Less Bloating
Lower Cholesterol
Lower Triglycerides
Better Vitamin Levels (please specify below)
Healthy Pregnancy
Improve Irritable Bowel Syndrome (IBS)
Less Emotional Eating/Binge Eating
Help with Eating Disorder
If applicable, describe your vitamin details:
Age:
Height:
Weight:
Do you exercise?
Yes
No
If yes, how often?
If yes, what types of exercises?
Foods and Allergies
Food allergies/intolerances:
Do you enjoy cooking?
Yes
No
Who cooks in your home:
Who shops in your home:
What types of grocery stores do you shop in? Check all that apply.
Big Grocery Chains
Wal-Mart
Drug Stores
Price Club (Sams, BJ's, other)
Online: Peapod, Shop Rite
Apps: Fresh Direct, other
Budget for food:
Tight
Medium
Unlimited
Do you experience food cravings?
Yes
No
If yes, what types of food do you crave?
Sweet
Salty
Crunchy
Only When Stressed
24-Hour recall (food and drink):
Breakfast:
Lunch:
Dinner:
Beverages:
A Typical Weekday
What time do you typically wake up?
Type of work you do? Check all that apply.
Desk Job
Manual Labor
Travel Often by Plane
Travel Often by Car
What time do you typically go to bed?
Your current stress level at work:
Very High
High
Medium
Low
More Details
Any foods you just don't like and do not want included in your meal plan?
How motivated are you to change your eating habits?
Very!
Somewhat
Not very at the moment but going to try
Comments, Questions or Concerns:
Word Verification:
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