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Sign Up Questionnaire

This questionnaire is only to be completed when you are ready to begin the Success Meals™ program. Please take your time and provide us with accurate and detailed information when filling out this questionnaire. The answers you provide are used to evaluate and establish your nutritional requirements.

General Information

First name:

Last name:

Birth date: / MM / DD / YY

Current body weight:

Body weight one year ago:

Height: ft. inches

Gender:

Address: City: State: Zip:

Daytime or work phone:

Evening or home phone:

Mobile phone:

Email:

Best time to contact: (i.e. mornings, midday, afternoon, after 5:00pm, after 6:00pm)

Please describe in detail the goal(s) you wish to obtain through the Success Meals™ plan?

How did you hear about us?

if other, indicate:

If radio, what station?

Mix 93.3 KUDL 810 AM Star 102
Oldies 95

If television, what channel?

Fox 4 KSHB NBC 41 Channel 9 KMBC
KCTV 5 38 The Spot UPN 62

If a newspaper or magazine, what publication?

Women's Edition KC Star
KC Sports & Fitness Verge
KC Business Journal

Nutrition

How many times a day do you eat?

Do you eat breakfast every morning?

yes no

Do you monitor your meal proportions?

yes no

What time do you eat breakfast?

am pm

Do you crave sweets or carbohydrates?

yes no

Do you limit your salt and sugar intake?

yes no

Do you include a protein source in every meal?

yes no

Do you struggle with hunger and/or cravings late at night?

yes no

Are you currently dieting?

yes no

Do you often skip meals or go more than six waking hours without eating?

yes no

Do you minimize your caffeine intake (coffee, tea, cola)?

yes no

Do you drink enough fluids to keep your urine pale yellow?

yes no

List all of your food dislikes:

These are foods that will be omitted or exchanged from your meals (example: bell peppers, onions, mushrooms)

Do you have any food allergies?

yes no

List your food allergies:

Please indicate which of the dietary guidelines you wish to have your meal profile structured after:

If you've selected to have Success Meals™, your dietitian, nutritionist, personal trainer, or yourself design your meal profile skip the next two questions and resume at the "EXERCISE" portion of this questionnaire.

I wish for Success Meals™ to design my meal profile based on my individual dietary needs and lifestyle goals.
My meal profile will be provided to Success Meals™ by my dietitian, nutritionist, personal trainer or by myself.
I wish for my meal profile to be structured after the mainstream diet regimen indicated below.

If you wish for your dietary needs to be structured after the specified guidelines of a "mainstream" weight management program, indicate which program from the adjacent list:

Success Meals will design my meal profile
I will be providing Success Meals with my dietary guidelines as determined by my dietitian, nutritionist, personal trainer or myself.
Atkins	South Beach
The Zone	Body for Life
Macrobiotic Diet	Sugar Busters
Vegetarian	Lacto-Vegetarian
Ovo-Vegetarian	Vegan
	Other

If other indicate:

Exercise

Are you currently exercising?

yes no

What time of day do you usually exercise?

am pm

How many times a week are you doing some type of cardiovascular exercise? (i.e. walking, jogging, running)

What is the duration of your cardiovascular sessions?

Check the types of cardiovascular exercise you currently participate in:

walking jogging treadmill elliptical training spinning	stationary bike recumbent bike bicycle aerobics class cross training
other, if other, please indicate:

Are you currently weight training as a part of your exercise program?

yes no

How many times a week are you weight training?

What is the duration of your weight training sessions?

How many times a week are you cross training? (Cross-training is a workout combining both aerobic and anaerobic exercise.)

What is the duration of your cross training sessions?

Do you often struggle with finding the energy to workout or complete a workout?

yes no

Is there any reason at all (health or personal) that would limit or prevent you from exercising?

yes no
If yes, please explain:

Energy

How are your energy levels through the day?

Do you need more energy or stamina during your workouts?

yes no

Do you get sleepy or lethargic after eating?

yes no

Do you get sleepy or lethargic in the mid afternoon hours? (i.e. 2:00 p.m.)

yes no

Rest

How many hours of sleep do you get on an average night?

Do you suffer from insomnia or have trouble sleeping?

yes no

Do you wake up feeling lucid, refreshed and energized?

yes no

Medical Information

Do you have any of the following conditions? Check all that apply:

diabetes high blood pressure gout hyperthyroidism hypothyroidism heartproblems arthritis asthma Crohn's disease iron-deficiency anemia sleep apnea cancer coronary artery disease ulcerative colitis	celiac disease cushings syndrome fibromyalgia osteoporosis osteoarthritis anxiety pancreas abnormalities depression eating disorders chronic fatigue syndrome low self-esteem distorted body image gallstones renal disease
insulin resistance, glucose intolerance inflammatory bowel disease (IBD) other, if other, please indicate:

Women's Health Questions

Are you post-menopausal?

yes no

So you suffer from hot flashes?

yes no

Are you pregnant or lactating?

yes no

If lactating, are you breastfeeding?

yes no

Are you within three month's post-partum?

yes no