Walk-In Order Form

The questionnaire below provides information necessary to analyze your Current Dietary Habits, and provide you with a complete nutritional evaluation. Take your time and answer each question carefully. You may want to print this out and read over it before filling it out online. The accuracy of your evaluation depends on the accuracy of your answers. Please complete all sections as they are required.

By Completing this Application / Order Form you ARE NOT OBLIGATED until we have received payment and started the program with you.


Contact Information
Name: Gender:
Address: Age:
City: State:
Zip:
Email: Home Phone:
Marital Status: Work Phone:
Body Composition
Height: Weight:
% Body Fat: Weight 1 Yr Ago:
Your Goals
% Body Fat: Weight:
Goals you wish to obtain:
Medical History
Heart Disease: Diabetes: Digestive Disorders:
Thyroid: High Blood Pressure: Hypoglycemia:
Anemia: Pregnant / Nursing: Other:
Nutrition Information
The following information is important in the design of your menu's, please take the time to answer the questions thoroughly.
1. Estimated calories consumed daily?:
2. What types of diets have you done?:
3. How often do you dine out?:
4. Do you snack after dinner?:
5. Do you like to cook?:
6. Glasses of water consumed daily?:
7. Weekly alcohol consumption?:
8. Please list EVERYTHING you ate yesterday (or a typical day):
For breakfast I would like:
OR OR
For lunch I would like:
OR OR
I have access to a:
Refridgerator Microwave Stove Cooler
For dinner I would like:
OR OR
For snacks I would like:
OR OR
My big splurge would be:
OR OR
Exercise
Daily: Multiple times/week: Weekly: Monthly: None: Unable:
Food Preference
When choosing the foods you would like to incorporate into your menu plans, please consider your lifestyle (budget, convenience, family, time management, etc.) Please take your time and be specific!
Type Likes Dislikes
Milk-Yogurt-Cheese-Eggs:
Meats-Poultr:
Meat Substitute:
Breads-Rice-Beans-Grains:
Fruits:
Vegetables:
Desserts:
Food Allergies:
Special Requests:
Instruction for completing the Food Intake portion
NOTE: It is not neccessary to complete all three boxes.

1. For each food item listed, put down how many servings you eat, either per day, pre week or per month. Pay special attention to the Serving Size of each food item listed. When your portion is different from the one given, adjust the number of servings you eat accordingly. Most importantly, be as accurate as possible.

2. Please put numbers in either the per day, per week OR per month column. Do Not complete all 3 boxes. You must use numbers or your nutrition report cannot be processed. No Check Marks. If you do not eat the food at all, put a ZERO.

Example:
# Day Week Month Serving Size Breads-Cereals-Grain Products
1. 2       1 slice Whole Wheat Bread

To calculate, take your usual serving size, and compare it to the one listed. If you have twice as much you would then double the number of servings entered in the day, week, or month box. For example, if you have whole wheat bread once per day, and your serving is 2 slices, then enter a 2 in the box for per day.
Food Intake Form
How often do you eat (or drink) the following?
Servings Per ________ (choose only ONE - Day, Week or Month for each line)
# Day Week Month Serving Size Breads-Cereals-Grain Products
1. 1 slice Whole Wheat Bread
2. 1 slice Sourdough or French Bread
3. 1 slice, 1/2 bun White Bread, Hamburger/Hotdog Bun
4. 4-6 ea Whole Grain Crackers (Wheat Thins. Rye Crisp)
5. 4-6 ea Refined Crackers (Saltine, Ritz)
6. 2 ea Graham Crackers
7. 1 ea Tortilla, corn, 6"
8. 1 ea Tortilla, flour, 10"
9. 1 ea Muffins (corn, bran, blueberry)
10. 1/2 ea English muffin, bdl, pita
11. 3 ea Pancakes
11a. 1 ea Waffles, 7" Diameter
12. 1/2 cup Whole Grain COOKED cereal (wheat, oats)
13. 1/2 cup REFINED, cooked cereals (cream of wheat, rice)
14. 1/2 cup 1pkg Instant Cooked cereals
15. 3/4 cup Cold Cereals, no sugar (shredded wheat, Nutrigraing)
16. 3/4 cup Bran type cereals (raison bran, branflakes)
17. 3/4 cup Cold Cereals with Sugar (frosted flakes)
18. 1/2 cup Granola
19. 1/2 cup Brown Rice, cooked
20. 1/2 cup White Rice, cooked
21. 1/2 cup Pasta's, cooked
# Day Week Month Serving Size Fruits
22. 1 ea Apple
23. 1 ea Banana
24. 1 ea Citrus Fruit (orange)
24a. 1/2 ea Grapefruit
25. 1 ea Peaches
25a. 1 ea Nectarines
25b. 3 ea Apricots
25c. 2 ea Plums
25d. 10 ea Cherries
26. 3/4 cup Berries, (strawberries)
27. 1/4 ea Cantaloupe
28. 1 cup Melons (watermelon casaba, honeydew)
29. 1 ea Pears, fresh
30. 1/2 cup Pineapple, fresh
31. 1 cup Grapes, fresh
# Day Week Month Serving Size Dried Fruits
32. 2 Tbsp. Raisins
32a. 2 ea Dates
32b. 2 ea Prunes
32c. 4 ea Apricots
# Day Week Month Serving Size Fruits Canned or Frozen
33. 1/2 cup Unsweetened Fruit
34. 1/2 cup Sweetened Fruit
# Day Week Month Serving Size Juices
35. 1/2 cup Orange or grapefruit, unsweetened
36. 1/2 cup Tomato or V8
37. 1/2 cup Other, unsweetened (apple, grape)
38. 1/2 cup Sweetened juices or nectars
# Day Week Month Serving Size Fats and Oils
39. 1 Tbsp Vegetable oils (corn, soy)
40. 1 Tbsp Olive oil
41. 1 Tbsp Shortening, Vegetable
42. 1 Tbsp Lard
43. 1 tsp Margarine
44. 1 tsp Butter
45. 5 ea Olives
46. 1/8 ea Avocado
47. 1 Tbsp Mayonnaise
48. 1 Tbsp Regular salad dressings
49. 1 Tbsp Low calorie dressings
50. 1 Tbsp Sour cream
51. 1 Tbsp Cream cheese
52. 1 Tbsp Half & Half
53. 1 Tbsp Whipping Cream
54. 1 Tbsp Coffee Whitener, imitation cream
55. 2 slices Bacon
# Day Week Month Serving Size Milk and Yogurt
56. 1 cup Non-fat milk
57. 1 cup Low-fat milk - soymilk
58. 1 cup Whole Milk
59. 1 cup Chocolate lowfat Milk
60. 1 cup Buttermilk
61. 1 cup Yogurt, lowfat plain
62. 1 cup Yogurt, lowfat with fruit
63. 1 cup Yogurt, nonfat with fruit
# Day Week Month Serving Size Vegetable
64. 1 cup Salads, lettuce, celery, green peppers
65. 1/2 cup Dark green leafy vegetables (broccoli, spinich)
66. 1 ea Carrots
67. 1 ea Tomatoes, fresh, medium
68. 1/2 cup Starchy vegetables (corn peas)
69. 1/2 cup Other cooked vegetables (green beans, cauliflower)
70. 1 ea Potatoes
71. 1/2 cup Sweet potato yams
72. 1/2 cup Winter squash (acorn)
# Day Week Month Serving Size Beverds
73. 1 cup Punch, Kool-aid
74. 12 oz Cola drinks w/sugar
75. 12 oz Diet sodas, cola type
76. 12 oz Non-cola drinks w/sugar (7-up sprite etc)
77. 12 oz Diet sodas. non cola
78. 1 cup Regular coffee and tea
79. 1 cup Decaf or non-caffeine beverds
80. 1 cup Hot chocolate or cocoa
81. 12 oz Beer
82. 12 oz Lite Beer
83. 4 oz Wine, sweet or dessert
84. 4 oz Wine, dry or table
85. 1 1/2 oz Liquor (run vodka)
# Day Week Month Serving Size Protein Foods
86. 1 cup Legumes (lentils, pinto beans, navy beans) cooked
87. 1/4 cup Nuts, seeds
88. 1 Tbsp Peanut Butter, nut butters
89. 4 oz Tofu
90. 3 oz Vegetarian meat subst, low fat (choplets linketts)
91. 3 oz Vegetarian meat subst, med fat (meatless, chicken)
92. 3 oz Vegetarian meat subst, high fat (wham fripats)
93. 3 oz Beef (rib roast, steak, veal)
94. 3 oz Beef, ground, cooked
95. 3 oz Pork (chops, roast, ham)
96. 3 oz Lamb (chops roast)
97. 3 oz Chicken or Turkey
98. 3 oz Fish, canned w/oil
99. 3 oz Tuna, water-packed
100. 3 oz Fish, fresh / frozen, no breading (trout salmon cod etc)
101. 3 oz Shellfish (shrimp. scallops)
102. 1 ea Eggs, large
103. 2 ea Egg whites only
104. 1/4 cup Egg substitutes
105. 1 oz Cheeses (cheddar, monterey jack)
106. 1 oz Cheeses, lower fat (swiss, mozzarella)
107. 1/2 cup Cottd cheese, regular
108. 1/2 cup Cottd cheese, low / non fat
109. 1 oz Lunch meats high fat (bologna, salami)
110. 1 ea Hotdogs
110a. 2 ea Sausd links
# Day Week Month Serving Size Desserts and Sweets
111. 2 ea Cookies
112. 1 ea Brownies, 1 1/2" x 1"
113. 1 ea Doughnut or sweetroll
114. 1 ea Cake without icing, 3" x 2"
115. 1 ea Cake with icing, 3" x 2"
116. 1 ea Granola bars
117. 1 slice Pie 1/8 pie
118. 1/2 cup Jello, regular w/sugar
119. 1/2 cup Jello, diet no sugar
120. 1/2 cup Pudding or custard
121. 1/2 cup Ice cream
122. 1/2 cup Ice Milk
123. 1/2 cup Sherbet
124. 1 ea Popsicles
125. 1 1/2 oz Candy bar, chocolate, M&M's
126. 1 1/2 oz Hard Candy
127. 12 oz Milkshake
# Day Week Month Serving Size Miscellaneous
128. 1 slice Pizza
129. 2 cups Popcorn, popped no oil
130. 2 cups Popcorn, popped with oil
131. 1 oz, 10-15 ea Potato Chips, Doritos
132. 1 Tbsp Catsup or Chili sauce
133. 1/2 cup Tomato Sauce
134. 5 slices, 1 Tbsp Pickles, pickle relish
135. 1 stick Chewing Gum, regular
136. 1 Tbsp Sauces (soy steak, BBQ)
137. 1/4 cup Gravy
138. 1 cup Soups (non-cream)
139. 1 cup Soups (cream)
140. 1 ea Fast foods (hamburgers, tacos)
141. 1 Tbsp Sugar, Honey, Jelly Syrups
# Day Week Month Serving Size Items not in above lists
A.
B.
C.
D.
Finish
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