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First & Last Name:

Email:

Tel:  

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Street Address:

City:

State:      Zip Code:

Best Time To Reach You:

Work Schedule: Which Best Describes Your Situation 9am - 5pm 3pm - 11pm 11pm - 7am At Home Part Time Job

Activity At Work 0r Home: Please Choose One I get minimal exercise weekly. I get moderate exercise weekly. I get plenty of exercise weekly.

Please Describe Any Exercise You Do:

WHAT, WHERE AND WHEN YOU EAT?

BREAKFAST:

When do you rise in morning….  average time:

Time you normally eat breakfast:

Your usual breakfasts consists of:
(Give two different examples of breakfasts you have.
Do you drink coffee at breakfast?... with cream?... sugar?...
Please be as specific as you can )

Morning snacks:

Does your place of work have vending machines:    Yes     No

What kind of foods are sold on your work premises:
(Coffee?.. Bagels?.. Donuts?... Candy?.... Junk Food?....
Healthy Choices?.... LOTS of Healthy Choices??... )


Do you drink water in mornings:    Yes     No

Lunch:

What Time (usually)  

Give 2 examples of Lunch Meals:
(Please be specific... i.e. sandwiches? What kind??
With mayo etc etc.. the more specifics… the better
we can coach you to great results)


What Liquids at Lunch:

Afternoon Snacks:

Give 2 Snack Examples:

Any Liquids in Afternoon?
Which Type:

Dinner:

What Time (usually):

Normal Protein Source: Which 2 Do You Most Frequently Eat?
(Fish, Chicken, Beef, Soy, Beans)

How Often Do You Eat Fried Foods: Please Choose One Often Sometimes Rarely Never

Carbohydrate Sources:
(Please give us an idea of the carbs you eat...
breads, potatoes, cookies, pasta's etc. Which are your favorites)

Liquids At Dinner:

Beverage Questions:

Diet Soda:
Number of Cans or Liters Per Day:

Regular Soda:
Number of cans or Liters per day:

Alcohol: Please Choose One Daily Weekends Only Rarely

Daily Water Intake: Please Choose Which Describes You Best Minimal At Least 64 Ounces Daily. LOTS and LOTS

 

Other:

Smoking: Please Choose One Do Not Smoke Light Smoker Moderate Smoker Heavy Smoker

Any Health Problems or Concerns?

On Any Medications?


Your Most Hungry Time Of Day:

Your Most Tired Time Of Day:  

Do You Go For Walks:
(Yes? No?... How long is your walk?... How Far?)



If we were to open up your refrigerator or freezer.....
what kinds of foods would we see:

Can you see yourself stocking your refrigerator
with Body Friendly foods like Fruits, Veggies, Water:

Yes      No

Is there a particular time or experience we should know about 
that relates to your weight?  Please describe:

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