HEALTHY MEALS, INC. MEAL PROGRAM CUSTOMIZATION QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your private record with Healthy Meals, INC.
YOUR NAME:
Last    First    Middle  
Username
Password
Sex
Male Female
Date of birth
Month  Day  Year
ADDRESS:
Street    City    State    Zip  
Home Phone
Cell Phone
E-Mail
A credit card will be required to initiate your membership. Please call the office with your payment information.
PHYSICAL STATISTICS
Age
Weight
Height:

Ft Inches
BODY TYPE:
Slender   Athletic   Normal/Slightly Over-Weight   20-40 lbs. Over-Weight   Obese   
EATING AND EXERCISE HABITS
EXERCISE:
Sedentary (No exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Choose your plan option:
   Individual   
   Family Flex       1 Week       1 Month    

What are your physical and wellness goals you wish to reach by becoming a member of Healthy Meals, INC?

Establishing your Customized Meal Program
Thank you for completing our questionnaire. Using the information provided from this questionnaire, we will establish a meal profile that is personally tailored to meet your individual characteristics, dietary needs, distinct food preferences, food aversions, and physical goals.

Because of our diverse health requirements and our individuality, it is quite simply not likely that a single diet plan can work for everyone. Optimal results are dependent upon the customized meal program you are individually set up with taking into consideration your age, weight, body type, metabolic rate, medical history and typical activity level.

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