Just complete the form and our nutrition experts can generate your custom

nutrition program. Your nutrition program will arrive in the mail soon, and one of our consultants will review it with you on the telephone.
Please send me a complete nutrition evaluation...
First Name:		Last Name:

E-mail Address:
Daytime Phone:
Evening Phone:

Current Information:
Weight:		lbs.	Height:		Ft. /		In.	Sex:	Choose Male Female
Birth Date:	Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003   (Required to calculate Age)
Body Fat %:	(Optional)				Waist Size:				In.

Target Information:

Your Desired Goal Weight:

lbs.

Rate of weight loss or gain per week:

Gain:

Loss:

Rate 0.5lb 1.0lb 1.5lbs 2.0lbs 2.5lbs

How many meals per day do you want to eat?	Choose 1 2 3 4 5
How many snacks per day to you want to eat?	Choose 1 2 3 4 5

How do you distribute the size of your meals and snacks?
Breakfast:	Choose Small Medium Large None	Snack:	Choose Small Medium Large None	Lunch:	Choose Small Medium Large None
Snack:	Choose Small Medium Large None	Dinner:	Choose Small Medium Large None	Snack:	Choose Small Medium Large None

List one or two favorite aerobic exercises you are willing to start or are already doing, such as aerobics, tennis, walking, cycling, swimming, etc. and which days (recommend 3 days per week minimum).

Activity 1:

Minutes:

Choose 10 min 15 min 20 min 25 min 30 min 35 min 40 min 45 min 50 min 55 min 60 min

Mon

Tue

Wed

Thu

Fri

Sat

Sun

(check all that apply)

Activity 2:

Minutes:

Choose 10 min 15 min 20 min 25 min 30 min 35 min 40 min 45 min 50 min 55 min 60 min

Mon

Tue

Wed

Thu

Fri

Sat

Sun

(check all that apply)

Do you have any specific preferences or intolerances concerning your diet?

Request Information on Turn-key Nutrition Program For Your Practice or Business

Christopher Fuzy MS, RS, LD Clinical Nutritionist Performing Nutritional & Metabolic Assessment

You have two choices: If you are located in South Florida, Call 954-561-0166 or 800-699-8106 to set up a complimentary nutritional consultation with one of our nutritionists in one of our offices. If you are out of the South Florida area, then please complete the Information Request Form and receive your information via US mail and we will review the information on the telephone per your request. New Client Questionnaire >Click here to print

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