Healthy Meals, INC.
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  
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.
PERSONAL HEALTH HISTORY
ANY CURRENT SPECIAL DIETARY NEEDS:
None  Diabetic   Vegetarian  Organic   Extreme Athletic/Competition   Other
List any medical problems doctors have diagnosed
How did you hear about us?
DO YOU HAVE ANY AVERSIONS OR ALLERGIES TO ANY SPECIFIC FOODS? PLEASE LIST BELOW:
1.       2.      3.    
4.       5.      6.    
7.        8.      9.    
10.    11.    12.  
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)
DIET:
Are you currently dieting?
   Yes      No
How often do you eat fast food or junk food?
   Rarely      Often
# of meals you eat in an average day?
Rank salt intake
   Hi      Med      Low
Rank fat intake
   Hi      Med      Low
CAFFEINE
   None      Coffee      Tea      Cola
# of cups/cans per day?
ALCOHOL
Do you drink alcohol?
   Yes      No
If yes, what kind?
How many drinks per week?
Have you considered stopping?
SLEEP
Do you get adequate sleep each night?
   Yes      No
Do you find yourself tired and lethargic during the day?
   Yes       No

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.

Welcome To Healthy Meals, INC.!!