Sign-up Questionnaire

Sign-Up Questionnaire

In order for us to provide the best customized healthy meal possible, please complete as many of the fields below as possible before submitting.

First Name
Last Name
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address
Best Time to Call
Birth Date
Gender
Weight (lbs)
Height (feet)
Height (inches)
Body Fat % (If Available)
How did you hear about us?
Are you currently exercising?
Aerobic Daily Exercise (cardiac training)
Aerobic Session Duration
Anaerobic Daily Exercise (resistance training)
Anaerobic Session Duration
Other Physical Activity
Do you have any physical or medical limitations that prevent or limit you from exercising?
If yes, please describe.

Waist Measurement (in inches)
The waist measurement is taken at the narrowest waist level, or if this is not apparent, at the mid point between the lowest rib and the top of the hip bone (iliac crest)

Hip Measurement (in inches)
The hip measurement is taken over minimal clothing, and is at the level of the greatest protrusion of the gluteal (buttock) muscles.

Do you crave carbohydrates and sweets?
Do you feel tired after eating?
Do you experience energy and mood swings?
Do you have hypertension (high blood pressure)?
Do you have high cholesterol?
Do you or anyone in your family have diabetes?
If yes, who?
If you have diabetes what type (type 1 or type 2)?
If type 1 (Insulin dependent) please indicate the amount of insulin that you use per day.
Are you within 20 lbs of your ideal or goal bodyweight?
Have you gained any significant weight in the past year?
If yes, how much? (lbs)
Do you have any food allergies?
If yes, list the foods.
List the foods that you have an extreme aversion to.
Do you require a specific diet regimen such as vegetarian?
Do you require a “low carb” diet regimen?
If yes, which low carb diet do you follow?
If Yes, describe.
On average, how many meals do you eat per day?
Do you eat breakfast on a regular basis?
Do you commonly eat after 8:00pm?
Do you make sure that every meal you eat contains a protein source?
Do you limit your meal portions or do you eat until you’re satisfied?
Please describe, in detail, the goals in which you wish to obtain through the “Success Meals” program.

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