THE PALM BEACH WAY PROGRAM LIFESTYLE ANALYSIS QUESTIONNAIRE
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Name: Last First Date:
Primary Phone: Alt. Phone: Email:
Would you like to be called for a follow-up? Meals/day?
Sex:
Age: Weight:
Desired Wt lbs.
Would you like to..? (Check all that apply)  
More energy: Better Sleep: Faster Metabolism:
Weight Loss : Strength Gain : Muscle mass :
Muscle tone/tighter skin : More Endurance: Healthier Appetite :
Medical History (Check all that apply)  
Mediactions: Type:  
Diabetes: Cancer tumors (past or present)
Thyroid Disease: Liver Disease: Insomnia:
Asthma: Arthritis: Anti-Depressants:
Glaucoma: Headaches: Heart Problems:
Digestive Problems: Constipation: Chronic Fatigue:
Pregnant or nursing: Prostrate Enlargement : Allergy Medicine:
Multiple Schlerosis: Acid Reflux: Hormone Imbalance:
Menopause (pre or post): IBS: Other:
Notes or Comments:
Important Nutrition, Wellness & Fitness Questions
 
What is your biggest meal of the day?    
Blood type: Body type:
How do you feel after you eat?
How much water do you drink daily?
How much refined sugar do you consume daily?
How much fruit do you eat daily?
How man fresh vegetables do you eat daily?
Do you drink liquor? Diet or regular soda?  
What starches do you eat daily?
How much fiber do you consume daily?
Do you eat canned food? Do you read food labels?
Do you eat out often? Do you eat alot of fast foods?
Do you eat alot of junk foods?
What are your eating weaknesses?
What are your eating strengths?
Do you have a good self image? Exercise per week.
Are you concious of your breathing?
Do you know how to meditate?
Are you hard on yourself?
Do you reward yourself with bad foods?
Do you binge if you're sad or depressed?
Do you finish things you start?
Do you need other people's approval?
What foods make you happy?
Do you have any food allergies?
If yes, what are they?
Do you consider food a friend or foe?
What is your favorite food? Nationality:
What is your ultimate health goal?
 
Acknowledgment
I hereby acknowledge that the above information is correct. I will not hold Brigitte M. Britton, Dr. Layne Nisenbaum, writers or consultants of "The Palm Beach Way Program of Eating and Balance" liable in any way for medical conditions that may arise now or in the future from the use of any suggested nutritional products or nutritional programs. I am also reminded that I should consult a physician before starting any nutrional and/or exercise program.
Click the checkbox to acknowledge.
 
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