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First Name *

Last Name *

Phone *

Email *

Date of birth *

Usual Weight *

Goal Weight *

Height *

Name Your Top 5 Favorite Foods *

Any food allergies? If so please list them: *

How many meals do you eat daily? *

What is your favorite snack? *

Do you drink alcohol? *

Yes

No

How many drinks do you have in week? *

0

1-2 Drinks

3-5 Drinks

6 or more Drinks

Do you ever eat for reasons other than hunger? *

Stress/anxiety

Social custom

Boredom

Tired

Other

Check all that you like *

Chicken

Salmon

Steak

Ground beef

Ground turkey

Shrimp

Cottage cheese

Yogurt

Nuts (Peanuts, Almonds, etc.)

Pasta

Rice

Sweet potatoes

Regular potatoes

Beans

What foods would you describe as your staple foods (eat almost on a daily basis) *

Do you like... *

Smoothies

Juices

neither

Any Questions For Me?

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