Page title

Contact Info

First Name

Last Name

Cell Phone

General Health & Nutrition Questions

Personal Info

Birthday

Current Weight

Height

Current Bodyfat

Lifestyle

How would you rate the activity level of your PROFESSION, or what you do during the day (non-exercise related)?

Your Goals

What are your Goals?

Protein Requirements

What is your Goal Weight?

Body Type

Which best describes you?

Food & Habits

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also indicate the time and amount.

What are your favorite foods?

What are the foods you dislike?

What time do you normally wake up?

What time do you normally go to bed at night?

If you smoke, how many cigarettes do you smoke per day?

If you smoke, how many years have you smoked?

If you drink alcoholic beverages, what and how many per day?

Are you allergic to any types or kinds of food?

Have you ever been placed on any type of nutritional program in the past?

If yes, by whom and what did it consist of? Please explain

What were your results?

Have you ever had your bodyfat tested?

If yes, how was it tested and when?

BY CLICKING THE "SUBMIT" BUTTON BELOW, I AM AGREEING TO ALLOW JAMES SIMPSON, WEIGHT MANAGEMENT CONSULTANT, TO DESIGN A WEIGHT MANAGEMENT PROGRAM FOR ME TO ENHANCE MY HEALTH & FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD JAMES SIMPSON OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING HABITS. I UNDERSTANT THAT JAMES SIMPSON IS NOT A REGISTERED OR LICENSED DIETITIAN, NOR A MEDICAL PRACTITIONER. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF MY OWN PRIVATE DOCTOR. I HAVE GIVEN JAMES SIMPSON ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.

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