Health Questionnaire

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Tandem Submission?

Why are we collecting this information?

The information gathered from the fields below enables us to customize your dietary regimen. We'll be able to determine the daily caloric amount and the macronutrient ratio that best suits your needs to put you on track to reach your health and physical goals. This will also ensure that any food aversions or other requested dietary needs are accounted for.

Name*

First Last

Sex*

Male

Female

Date of Birth*

Primary Phone*

Used for order confirmation.

This is my:*

Secondary Phone

Optional

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This is my:

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Delivery Address*

Street Address City State ZIP Code

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)

Note: We can accommodate any dietary restrictions you might have and also any strong food aversions. Please only list any strong aversions you have so that you can try things you are normally less likely to try. The more aversions you list, the less variety you will receive.

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If you are ordering for another person, add any special dietary information here.

Weight*

Height*

Body Type*

Exercise*

How may CUPS of caffeinated drinks do you have per day?

Do you drink ALCOHOL?*

What kind of alcohol do you drink? (check all that apply)*

Beer

Wine

Liquor (whiskey, scotch, vodka, tequila, etc.)

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?*

How did you hear about us?*

Email*

Health Questionnaire

Why are we collecting this information?

Scott Kluck