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Your Current Weight			Weight You Want to Achieve
pounds kilograms
Height	feet meter	Inches
	snack through the day?	Yes		No
	snack late at night?	Yes		No
	eat when angry or depressed?	Yes		No
	need motivation?	Yes		No
	want the family to eat the same meal?	Yes		No
How many people do you cook meals for?


Health Status
Do you suffer from any of the following? Check appropriate boxes
Diabetes High Blood Pressure Glycoma Food Allergies
Other - Please Specify

If you suffer from food allergies, which foods are you allergic to?

Activity Level. Please check one of the appropriate boxes
Not Active Active Moderately Active


Your Profile

First Name
Last Name
Email Address privacy policy strictly enforced
Female Male
How did you find this site ?
Breakfast
How often do you eat breakfast each week?
0 -1 2 - 4 5 - 7
What do you normally eat for breakfast?

Snacks/ Lunch / Dinner
				How often do you eat dessert for dinner?
				Seldom Occasionally Often
				How many nights each week do you snack after dinner?
				0 - 1 2 - 3 More than 4
				What type of snacks do you eat, if any?

What types of meats do you usually eat for dinner?

How many days per week do you eat out? 0-1 2-4 5-6 More than 7
How often do you crave sweets? Seldom Occasionally Often
We can include fast food suggestions to your plan. Do you wish to include the fast food lunch option in your diet plan? Yes No Please click the submit button. You will automatically be taken to the sign up page to access your ePlan.

Diet Center - how to lose weight

Diet Forum
5342 W. 125 Street, Del Aire, CA 90250
(310) 643-5211 editor@dietforum.com

Information contained in Diet Forum is for increased awareness of diet and nutrition and in no way should be substituted for medical attention. Consult your physician for diagnosis or treatment and before beginning any diet or exercise program