Focused on Fitness TM
Healthy Food Questionnaire

Name:     
Address:  
City:        State:
Day Phone:   Evening Phone:
email:    

Reason(s) for utilizing this service. Check one or more that applies to you.

Lose weight Dietary restrictions
Control diet Diabetic
Feel better Dr's advice
Convenience Gain Weight
Other(s)  


Results from other diets you have tried:

 GoodBadUnsure
Atkins
Zone
South Beach
Wt. Watchers
Jenny Craig
Other

(Please specify)


Favorite Foods:

Meats:
Poultry:
Seafood:
Vegetables:
Fruits:
Starches:
Meals:

List any foods to which you are alergic:


How many dinners per week are you interested in?
How many lunches per week are you interested in?
Do need help with shopping for groceries? Yes No

Please print and bring this form to our studio. You may also fax it to us at 508.315.3396.