Nutrition Club Site

Sign-Up

Please fill out the registration information below and a wellness coach will contact you with in 24 hours to get you registered.

For your security registration fee’s will be taken over the phone. All major credit cards accepted.

Basic Information

(* denotes required fields)

*First Name

*Last Name

Address

City

State

Zip

Phone

*Email

Age

Height

Weight

How did you hear about us:

Wellness Evaluation Questionnaire

1. Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roasts and other red meats?	Yes No
2. Do you eat a variety of colorful fruits and vegetables and do you eat at least seven servings a day of these?	Yes No
3. Do you consume primarily whole grain (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?	Yes No
4. Do you eat ocean-caught fish at least 3 times per week?	Yes No
5. Do you avoid fried foods, dressings, sauces, gravies, butter and/or margarine?	Yes No
6. Is your digestive system free of indigestion or irregularity?	Yes No
7. Do you get a minimum of 30 minutes exercise 3-5 days a week?	Yes No
8. Do you maintain a stable and appropriate weight?	Yes No
9. Do you usually have time to prepare balanced meals, rather than take out or eating on the run?	Yes No
10. Do you stay away from soda and typical snack foods throughout the day and after dinner?	Yes No
11. Are you free of water retention and bloating?	Yes No
12. Do you have the energy and focus you need to meet your daily challenges?	Yes No
13. Do you drink at least 8 glasses of water a day?	Yes No
14. Are you getting your daily recommended allowance of Calcium? a. Men = 1,000 mg b. Women under 50 = 1,200 mg c. Women 50+ = 1,500 mg	Yes No
15. Are your blood pressure, triglycerides and bad cholesterol levels in the normal range?	Yes No
16. Men: Are you free from problems associated with your prostate such as slow urination or waking up at night to urinate?	Yes No
17. Women: Are you free from problems associated with menstrual cycles/menopause, mood changes, hot flashes or problems sleeping?	Yes No
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