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Done For You Meal Plan Assessments

Please fill out the questionnaire so I can begin creating meal plans customized for you.

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Question 1 of 24

Full Name

Question 2 of 24

Email

Question 3 of 24

Phone number

Question 4 of 24

Date of birth

Question 5 of 24

Gender

A

Male

B

Female

Question 6 of 24

Height in feet and inches

Question 7 of 24

Weight in pounds

Question 8 of 24

Goal weight in pounds

Question 9 of 24

Physical activity

A

Sedentary - little or no exercise and a desk job

B

Light exercise or sports 1-3 days/week

C

Moderate exercise or sports 3-5 days/week

D

Hard exercise or sports 6-7 days/week

E

Hard daily exercise or sports or physical job

Question 10 of 24

Which best describes the diet of your household

A

Eats most things

B

Lacto-ovo vegetarian (eats plant based + dairy + eggs)

C

Lacto vegetarian (eats plant based + dairy)

D

Ovo vegetarian (eats plant based + eggs)

E

Vegan (eats strictly plant based diet)

F

Pescatarian (eats plant based + fish/seafood)

Question 11 of 24

Select any and all of the foods listed that you and your family choose to avoid.

(Select all that apply)
A

Wheat/Gluten

B

Grains (non gluten containing grains)

C

Milk/Dairy

D

Eggs

E

Soy

F

Fish

G

Shellfish

H

Peanuts

I

Tree nuts

J

Sesame

K

Beef

L

Pork

M

Lamb

N

Game meats

O

Poultry

P

Grains

Q

Legumes

R

Corn

S

Nightshades (white potatoes, peppers, eggplant, tomatoes)

Question 12 of 24

Do you like to have leftovers included in your meal plan?

A

Yes

B

No

Question 13 of 24

If you do like to have leftovers, how many days of leftovers would you consider using from a meal?

A

I do not want to have leftovers

B

1 day

C

2 days

D

3 days

E

New Choice

Question 14 of 24

How many additional adults will be included in the meal plan? (Do not include yourself, for teens include them as an adult, enter 0 if none.)

Question 15 of 24

How many pre-teens will be included in the meal plan? (enter 0 if none)

Question 16 of 24

How many children will be included in the meal plan? (enter 0 if none)

Question 17 of 24

Please check any of your current health conditions.

(Select all that apply)
A

B12 deficient anemia

B

Iron deficiency anemia

C

Bariatric stage 4

D

Celiac Disease

E

CKD Stage 1-2

F

Diabetes Type 1

G

Diabetes Type 2

H

Pre-Diabetes

I

Diverticulitis

J

Diverticulosis

K

Heart Failure

L

High Cholesterol

M

Hypermetabolism

N

High Blood Pressure

O

Low Sodium

P

Overweight/Obesity

Q

Osteoporosis

R

I have no health concerns. I would like to eat an overall healthy diet.

Question 18 of 24

How would you describe your cooking skill?

A

Beginner

B

Intermediate

C

Advanced

Question 19 of 24

Which meals are the most challenging for you to eat well?

(Select all that apply)
A

Breakfast

B

Lunch

C

Dinner

D

Snacks

Question 20 of 24

How many days of meals would you like included in your weekly meal plan? (Note you can delete meals from each individual week if one week you would like 5 and the following week you only need 4.)

A

1 Day

B

3 Days

C

5 Days

D

7 Days

Question 21 of 24

What are foods you like to eat for breakfast?

Question 22 of 24

What are foods you like to eat for lunch?

Question 23 of 24

What are foods you like to eat for dinner?

Question 24 of 24

 

The menu plans I will receive are provided for informative purpose.  Recommendations are not based on an in-depth assessment and treatment process as would be found in a client-clinician relationship. While I am a Registered Dietitian, the information contained is not intended to be a substitute for individualized medical advice. You agree not to hold the Company or individual(s) providing the information liable for any errors or omissions, loss or damage you may incur. Always seek medical advice for your individual circumstances and conditions. 

A

Yes, I understand and agree to the terms and conditions of the Done For You Meal Plans.

B

No, I do not agree to the terms and conditions of the Done For You Meal Plans.

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