[Under Construction]

To assist our clients in understanding our services, we are offering a FREE dietary consultation, for a short introductory period, using the government's Body Mass Index as a guide.  By completing the form below we will give you basic, preliminary information about your dietary and nutritional needs.  This introductory offer is FREE!

Key Benefits

bulletLearn how your body size compares with government standards
bulletObtain a Professional nutritional evaluation 
bulletDetermine if you need further assistance in this area

 

 

Information Request Form

Complete the following form.  This information will be kept strictly confidential.  We will respond to you within approximately (5) business days.

MEDICAL HISTORY
Name:
Your e-mail:

Date: _/_2000
Are you male or female: m or f
Height (inches)
Weight (lbs.)
How many lbs. would you like to lose?
How is your blood pressure?
l-low,n-normal,h-high
Do you smoke cigarettes?
y-yes, n-no
Do you have diabetes?
Do you have heart problems?
Family History:
Heart Disease?
Diabetes?
High Blood Pressure?
Do you exercise on a regular basis?
How long ago did you weigh
the weight you were happy with? 		years
How many previous attempts
have you tried to lose weight:
Enter any additional information or
questions you might have in the following:
   

FOOD RECORD
Your e-mail:

Name:

Food(s) Eaten
Date

ex. Mon. Feb. 12 		Time

ex. 7:00 AM 		Food

ex. banana 		Amount

ex. 1/2, whole 		Hunger level

ex. 1-5(5 highest)
   

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Copyright © 2001 Healthy Bytes Inc.



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