Consulting Form
Name:
Email address:
Mailing Address
I am ready to make changes to my lifestyle
Clear selection
I have the support from those around me to make changes
Clear selection
The thing(s) I need most help with in the next 90 days is:
On a typical day I eat (including snacks):
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In a typical week I prepare all my meals at home:
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Who prepares most of the meals you eat?
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I feel confident that I eat the right amount of vegetables throughout the day
Very confident
Not at all
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I feel confident that I eat the right amount of protein throughout the day
Very confident
Not at all
Clear selection
I feel confident that I eat the right amount of carbohydrates throughout the day
Very confident
Not at all
Clear selection
I read nutrition labels:
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The majority of the time the main reason I eat is because:
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Eating Habits (check all that apply)
Additional Comments of Concerns:
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