Weight:		lbs.	Height:		Ft.		In.	Sex:	Choose Male Female
Birth Date:	Month January February March April May June July August September October November December / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
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% Healthy range females 16 - 24%

How many meals per day do you want to eat?	Choose 1 2 3 4 5
How many snacks per day to you want to eat?	Choose 1 2 3 4 5

How do you distribute the size of your meals and snacks?
Breakfast:	Choose Small Medium Large None	Snack:	Choose Small Medium Large None	Lunch:	Choose Small Medium Large None
Snack:	Choose Small Medium Large None	Dinner:	Choose Small Medium Large None	Snack:	Choose Small Medium Large None

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.

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?	Choose Scale Hand held device Skin Calipers Electrodes
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

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