CLIENT APPLICATION - YOUR INFORMATION IS PRIVATE

 

Name:
Phone:
Email:
..
Height:
Weight:
Age:
Occupation:

 
1. My primary reason for seeking nutritional/lifestyle guidance is:

 
2. I consider my nutritional strengths to be:

 
3. I consider my nutritional weaknesses to be:

 
4. My current dietary regiment generally consists of:

Breakfast:
Lunch:
Dinner:
Snacks:
Beverages:

 
5. My favorite foods are:

 
6. My least favorite foods are:

 
7. My current exercise/activity regiment (if applicable) consists of:

 
8. My previous experience with nutritional/lifestyle programs and/or diets include:

 
9. I have the following medical conditions that my affect my regiment (if applicable):

 
 
Additional Notes:

Privacy - Your information will not be shared with any other business, person, or organizational entity.  Your information is used only for program evaluation at LA Health Works.