YOUR HEALTHY EATING PLAN STARTS HERE

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1. Please describe your current food preparation.	Cook meals from scratch Combined meals - portion from scratch, portion pre-packaged Entirely pre-packaged with addition of a few ingredients. milk, eggs Completely pre-packaged Someone else prepares meals for you Other
2. How many times per week do you eat out?
Please list restaurants visited most frequently
3. Which of the following do you consistently eat each day	Breakfast Morning snack Lunch Afternoon snack Dinner Evening snack
4. What changes do you feel you need to make in your current eating habits?
5. What are your nutrition and /or fitness goals? What goals are you going to accomplish with a healthy eating plan and lifestyle change?
6. Do you have any special considerations or preferences regarding your nutritional plan?
7. Have you participated in diets in the past?
I yes, please describe the diet and its success below. ie what type of diet was it, duration, and results
8. Do you take any nutritional supplements?	Meal replacement shake or bar Extra protein supplement Multivitamin Energy drink All of the above Other
9. Please identify any current or potential obstacles that may challenge your desire to obtain a healthier lifestyle. ie time, money, family, etc
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