Weight Management Evaluation for Body Mass Index, Daily Protein and Calorie Requirements

First Name   Last Name

      Height   Weight    Age

        Email Today's Date

Telephone

          City State Country (if outside USA)

Your current eating habits:

1. How many meals a week do you eat with poultry or soy protein

2. How many meals a week do you eat red meat?

3. Are you mostly vegetarian or vegan?

4. Do you primarily consume whole grain (bread, pasta, brown rice)    Yes  No

5. How many times a week do you eat fast food? 

6. How many times a week do you eat out (non fast food)?

7. How many times a week do you eat ocean caught fish?

8. Do you have any indigestive problems (heartburn, excessive burping, pains)

9. Do you have time daily to prepare balanced nutritious meals?

10. How many sodas (or high energy drinks) do you have a week?

11. Are your cholesterol and triglycerides in normal range?

12. How many times a week do you exercise for at least 20 minutes?

13. Is your daily energy level low, medium or high?

14. Is your stress level low, medium or high?

15. Is your blood pressure in the normal range? Yes  No 

16. What is your weight loss goal and in what time period? What have you tried to get there and results? Do have heartburn or heart related (blood circulation) problems or other health issues?

18. I am interested in purchasing weight management products at wholesale prices (call me)Yes  No

   Your weight management evaluation and protein recommendation will be emailed to you.