Health Questionnaire

Name*
First Last
Sex*
- Male
- Female
Date of Birth*
Address*
Street Address City State ZIP Code
Home Phone*
Email*
Meal Plan Option*
IMPORTANT - CURRENT SPECIAL DIETARY NEEDS:*
List ANY medical problems doctors have diagnosed*
List ANY strong food aversions or allergies to ANY specific foods (see note below)*
Within my meal regimen I'd like to request the following: Note: Your macronutrient portioning (daily percentage of proteins versus complex carbohydrates versus essential fats) will be customized based on this questionnaire and specific requests you make
Weight*
Height*
Body Type*
Exercise*
Are you curently dieting*
How often do you eat fast food or junk food?*
No. of meals you eat in an average day?*
Rank your SALT intake*
Rank your FAT intake*
Do you drink coffee or caffeinated drinks?*
How may CUPS of caffeinated drinks do you have pre day?*
Do you drink ALCOHOL?*
if YES, what kind (check all that apply)
- Beer
- Wine
- Liquor (whiskey, scotch, vodka, tequila, etc.)
How MANY drinks are you likely to consume per week?
How MANY HOURS of sleep do you get per night?*
Do you find yourself tired or lethargic during the day?*
What are your physical and wellness goals you wish to reach by becoming a member of Healthy Meals, INC?*
How did you hear about us?*
Email
This field is for validation purposes and should be left unchanged.

Are you ready? Ready to add convenience, great nutrition, and healthy eating habits to your life? Well, we’re ready to help you get started. Call or email us right now, and we’ll get you on your way to reaching your goals – whatever they may be – and to help you simplify and add balance to your life.

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816.587. MEAL (6325)