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Nutrition Registration Form - 3 Month Membership
1. Patient
(Required)
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Phone
(Required)
Select Gender
Male
Female
Other
Birthday
MM slash DD slash YYYY
Referred by
Weight?
(Required)
Height?
(Required)
Do you have any medical conditions?
(Required)
Yes
No
Please specify
(Required)
Medications or supplements currently taking?
(Required)
Do you have any allergies (food or non-food)?
(Required)
Do you have any food dislikes?
(Required)
How would you describe your daily activity level?
(Required)
Sedentary (little or no physical activity)
Lightly Active (light exercise or daily activitys)
Moderately Active (exercise 3-5 times per week)
Very Active (hard exercise or physical job)
What is your occupation?
(Required)
How would you rate your stress level?
(Required)
Low
Moderate
High
How many hours of sleep do you typically get per night?
(Required)
Less than 4
4-6
6-8
More than 8
How many meals do you eat per day?
(Required)
1-2
3-4
More than 4
Do you have any dietary restrictions or preferences?
(Required)
How often do you eat out?
What are your primary health or nutrition goals? (Choose all that apply)
(Required)
Weight loss
Improve energy levels
Manage a medical condition
Build muscle
Do you face any challenges in maintaining a healthy lifestyle?
(Required)
Cravings
Time constraints
Lack of knowledge
Important Reminder: Please avoid eating, drinking, or engaging in any physical activity at least two hours before your appointment. These actions may lead to inaccurate readings. Thank you for your cooperation!
Cancellation Policy Agreement
(Required)
I understand and agree that if I fail to fulfill the terms of the contract or discontinue services prematurely, 50% of the remaining balance for the agreed-upon plan will be charged.
I agree to these terms.
Signature
(Required)
Signature
Date
(Required)
MM slash DD slash YYYY
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