OFFICIAL NUTRITION QUESTIONNAIRE AND GOAL ASSESSMENT FORM

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Please fill out this quick questionnaire so our nutritionist can provide meal plans tailored to you.

Email *

Full Name *

Address (for-delivery) *

Phone number

Height *

Weight *

Age

Goal Weight *

Would you like to be on our e-mail list?
*

Yes

Choose your program
*

21-Day Reset (3 Weeks, Monday-Sunday)

5 Days On, 2 Days Off (15 Days, Monday-Friday)

6 Days Optional (Monday-Saturday)

Choose your start date

YYYY

Choose Your Pick-Up Or Delivery Days
*

Monday & Thursday

Wednesday & Saturday

Tuesday & Saturday

Do you have any specific food intolerances/sensitivities?
*

If you have any food allergies please list these at the 'comments' section at the end of the form.

Yes

Do you have diabetes or borderline diabetic?

Yes

Clear selection

Do you have high cholesterol?
*

Yes

Do you have high blood pressure? *

Yes

Are you taking any medications?
*

Yes

What are your eating patterns?

If you have selected 'Other' please specify at the 'comments' section at the end of the form.

3 meals with snacks per day

3 meals, no snacks per day

I’m a grazer

I’m a morning eater

I’m an afternoon eater

I overeat in the evening

Other: (Please list this in the 'comments')

Clear selection

What style of meals are you interested in?
*

*We currently do not offer programs for only vegetarian or keto meals

Balanced

Low Carb

Vegetarian

Keto

All of the Above

Required

Are you gluten sensitive?

Yes

Clear selection

Are you dairy sensitive?

Yes

Clear selection

Can you have some gluten, just not all the time?

Yes

Clear selection

Can you have some dairy, just not all the time?

Yes

Clear selection

Do you prefer to pick out your own meals?

Yes

Clear selection

Protein Snacks
*

Check the box if yes to the following options

Turkey Slider Patty

Satay Chicken

BBQ Chicken

Honey Sriracha

Turkey Meatloaf Ballz

Tuna Melt

Roasted Red Bell Pepper Hummus

Eggcellence Salad

Required

Delights
*

Check the box if yes to the following options

Flourless Brownie (GF)

Peanut Butter Chocolate Chip Energy Bite (GF)

Pistachio Tahini Energy Bite (GF)

Reduced Fat Blueberry Muffin

Reduced Fat Chocolate Muffin

Reduced Fat Zucchini Chocolate Chip Muffin

Trail Mix

Required

Below are menu items that you may not consume due to allergies or religious beliefs

Check yes if you may not consume

Asian Salmon (Seafood)

Vegetable Shrimp Pad Thai

Creamy Shrimp Florentine (Seafood)

Salmon Squares (Seafood)

Cape Cod Cakes (Seafood)

Carnitas Bowl (Pork)

Carolina Pulled Pork (Pork)

Comments Section

(Please specify your answers to any above questions)

What are your eating patterns? (If other was selected)

What are your food sensitivities? (If other was selected)

We require a 48-hour notice in the event you are unable to complete the program. If we are not provided a 48-hour notice prior to your following pickup, you will be charged for that pickup only.

We require a credit card on file:
Please provide this to us either by
Phone: 832.437.2229 or In-person: 1315 W. Grand Parkway S. Katy TX, 77494

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