Complete all information and receive a free, individualized dietary and meal plan!
All information provided is confidential and will not be shared with anyone without your permission.

Name:

Birthdate (MM/DD/YYYY):
Address
(number, street, city, state, zIp):
Email:

Phone:


Height:
(eg 5'4")

Weight:

Male Female

Are you currently participating in a fitness program?

Yes No

Activity Level:

No Exercise
1-2 Sessions/Week
3-4 Sessions/Week
5 Sessions/Week
6-7 Sessions/Week

 

 

WHAT

Note: Keep in mind that we are looking to understand how you eat to design a diet plan, not to trap you. Be sure to answer truthfully so we can create a plan that will actually work for you!

1. I feel tired and heavy after eating meat.

Often Sometimes Not very often

2. I like and/or desire meat.

Often Sometimes Not very often

3. I like and/or desire breads/pasta.

Often Sometimes Not very often

4. I like and/or desire creamy/buttery foods.

Often Sometimes Not very often

5. My comfort foods (foods I prefer when I want to feel cozy) are:

Creamy & Hearty It varies Fresh, light & leafy

6. I desire sweets/candies (including chocolate):

Often Sometimes Not very often

The following statements are TRUE for you:

7. Everything is better with bacon.

Often Sometimes Not very often

8. Everything is better with ranch dressing, mayonnaise and/or butter.

Often Sometimes Not very often

9. Everything is better with sugar and/or ketchup.

Often Sometimes Not very often

10. I consider myself a vegetarian. Yes No

11. I am a vegan. Yes No

WHEN

12. I am hungry mostly in the:

Morning Afternoon Evening

13. I feel tired throughout the day.

Often Sometimes Not very often

14. I have problems sleeping at night.

Often Sometimes Not very often

15. I prefer to exercise in the:

Morning Afternoon Evening

16. My work starts usually in the:

Early Morning 4-7:30am Morning/Afternoon 8am-noon
Evening/Night noon-4am

17. I use coffee and/or energy drinks as a "pick-me-up."

Often Sometimes Not very often

18. I wake up in the morning achy and stiff.

Often Sometimes Not very often

19. My energy seems to crash in the afternoon.

Often Sometimes Not very often

20. When do you lack energy most?

Morning Afternoon Evening

HOW

21. I grew up eating a lot of big meals.

Often Sometimes Not very often

22. I prefer to eat 2-3 big meals each day.

Often Sometimes Not very often

23. I enjoy a big breakfast.

Often Sometimes Not very often

24. I enjoy a big dinner.

Often Sometimes Not very often

25. I enjoy a big lunch.

Often Sometimes Not very often

26. I prefer to snack or graze throughout the day.

Often Sometimes Not very often

27. I enjoy a snack before bed.

Often Sometimes Not very often

Any dietary program I use MUST have this food on it, or I won't be able to stick to it:

I have to have...

CHECK ALL THAT APPLY

Heart trouble	Sedentary / No exercise	Diabetes
Chest pains	Age 65+	Family history of heart disease
Faint/dizziness	Diagnosed hypertension	Chronic illness/condition
High blood pressure	High cholesterol	Recent surgery
Bone joint problems	Smoker	Pregnant

No medical conditions