Physical Wellness Program
Lifestyle Nutrition Inc.
Physical Wellness Program

Complete The Meal Plan Questionnaire For Your Custom Nutrition and Exercise Program.
Request a Private Webinar To Review Your Nutrition Program.
  *Required      
  *First Name *Last Name  
  *Speciality *Office Assistant Name  
  *Address
*City *State *ZIP
       
  *Daytime Phone Evening Phone  
  *Email    
  *Confirm Email    
 
 
Height: Ft. In Sex: Weight lbs.  Birth Date
Your Estimated Body Fat %:   Your Personal Goal Weight  
Rate of Weight Loss/Gain per week:    
The Lifestyle Metabolic Analyzer Accurately Provides Metabolic and Body Composition Data

Please estimate your body fat for demonstration purposes.

Basic guidelines healthy range males 11 - 15%

Basic guidelines healthy range Males 11 - 15% Healthy range Females 16 - 24%

How many meals per day do you want to eat?     Meals   snacks  
What size are your meals and snacks?          
Breakfast: AM Snack: Lunch:
PM Snack: Dinner: Bedtime Snack:
List one or two favorite aerobic exercises you are willing to start or are already doing, such as aerobics, tennis, walking, cycling, swimming, etc. and which days (recommend 3 days per week minimum).
  Activity 1 Minutes:  
 
Mon Tue Wed Thu Fri Sat Sun
(check all that apply)
 
  Activity 2 Minutes:  
 
Mon Tue Wed Thu Fri Sat Sun
(check all that apply)
 
  Activity 3 Minutes:  
 
Mon Tue Wed Thu Fri Sat Sun
(check all that apply)
 
Most doctors use the default meal plan.
We can provide a default meal plan based on your metabolism, lean mass, age, sex,
ht, wt & activity level or you can specify what type.
Individual Food Preferences will be addressed during the webinar
Default Meal Plan       Zone       South Beach      Paleolithic       Diabetic       Sports Nutrition
AM Heart                   Vegetarian      Pritikin Like      Food Combining      High pH Diet Type Atkins Pain Mgt. Arthritic           Pregnancy     Chronic Fatigue      Fibromyalgia
Body Fat Measured by Scales or Hand Held Devices are Not Accurate but we can use this body fat reading for demonstration purposes.
How did you estimate your body fat?
Name of device:

What day and time would you prefer a webinar with a nutritionist to review your nutritional program
and the economic benefits of the program to your specific practice?
Comments
 
 
I am primarily interested in
(Please check at least 1).
Scientific Validity
Cash Income Potential
CPT Insurance Income Potential
Medical or Health Risk Assessments
Practice Building Marketing Tool
Corporate Wellness Program
Elevate Current Nutritional Program / Products
Weight Management
Disease Management
 
Lifestyle Nutrition Inc

1061 W Oakland Park Blvd. Ste 222
Fort Lauderdale Florida 33311
800-699-8106 954-561-0166
Fax 954-200-6156