INFORMATIONAL QUESTIONNAIRE

Name: Date of Birth:

Address: Gender:

City: State: Zip Code:

Email Address: Phone Number:

Preferred start date of program:Preferred contact method (via phone or email):

Past Medical History and Dietary Information

Personal Information

Height:

Weight:

Briefl y describe past and current medical history, including injuries, illness, allergies, etc.

Please list any specifi c food patterns you follow (e.g vegetarian, no red meat, etc.):

Please list any food allergies, sensitivities, or intolerances you currently have:

Foods you will not eat (be specifi c: e.g. red onions, salmon, mushrooms, protein bars, etc.):

List any upcoming food-centered special events or occasions you have planned:

INFORMATIONAL QUESTIONNAIRE21/28 INFORMATIONAL QUESTIONNAIREINFORMATIONAL QUESTIONNAIRE21/28 D

AY FOOD CHALLENGE

Please briefl y explain the exercise pattern that you anticipate following during your challenge:

21 Day Challenge

28 Day Challenge

The 21/28 Day Challenge is a non-refundable program. In order to be successful, 100% compliance is needed. After initiating your Challenge, one change is permitted to your meal plan. One to two business days are required to complete requested changes.

If a change or cancellation is made within less than 24hrs, or if you do not show up for your appointment, you will be charged a $40 late cancellation fee. Initials:

21 Day Challenge

28 Day Challenge

Week 1 Stage 2 Stage 1

Week 2 Stage 4 Stage 2

Week 3 Stage 5 Stage 4

Week 4 Stage 5 Substitute Vegan Protein Powder for only $30

MENU (please check all that apply)MENU (please check all that apply)21/28

(please check all that apply)(please check all that apply)21/28 D

AY FOOD CHALLENGE

BREAKFAST:

Triple Berry Vanilla Muffi n

Mixed Berry Pancakes

20/20 Van. Shake + Berries + PB

20/20 Choc. Shake + Berries + PB

Vegan Choc. Shake + Berries + PB

LUNCH & DINNER:

SNACKS:

Lemon Almond Poppyseed Muffi n

Sundried Tomato and Spinach Frittata

Asian Chicken Salad

Thai Salad with Spicy Shrimp

Salmon Kale Caesar Salad

Chef Salad

Mediterannean Salad

Mesquite Chicken Salad

Chicken Caesar Salad

Fall Harvest Salad (seasonal)

Summer Fennel Salad (seasonal)

Salads

20/20 Cocoa Almond Bar

20/20 Chocolate/Vanilla Dry Powder Shake

Vegan protein powder shake

Metabolic protein powder shake

Tuna Salad

Cruncha Mame Edamame

�20/20 Chocolate Peanut Protein Bar

Jerky

20/20 Yogurt Peanut Protein Bar

Hard-Boiled Eggs

�Nuts & Nut Butter

Entrees Prawn Fradiavolo

Roast Beef Dinner Chicken Cabbage Enchiladas

Roast Beef and Blue Cheese Lettuce Wrap

Chicken with Pesto Zucchini

Tofu Veggies and Curry Sauce

Turkey Meatballs and Spaghetti Squash

BBQ Turkey Breast side

�High Protein Tofu w/ Hoisin Sauce

�Lacinato Kale Salad

Grilled Salmon Side

Veggie Tray w/ Roasted Jalapeno Dip

Caulifl ower Fried Rice

Grilled Chicken Breast

Chicken Souvlaki with Tzatziki Sauce

Ratatouille

A la Carte

Tarragon Chicken Salad Biscuit Chicken and Veggie Saute with Peanut Sauce

Vegetarian Pad Thai Turkey Meatballs with Coleslaw

�Alaskan Salmon Cake

Veggie Tofu Scramble

Carrot-Walnut Muffi n

Mediterranean Omelet

Chorizo Scramble

Caramelized Onion and Mushroom Frittata

Orange Cranberry Muffi n

String Cheese

Darigold 2% Cottage Cheese Fage 0% Plain Yogurt

Fruit Chobani Flavored Yogurt

To schedule or reschedule follow up appointment, contact 20/20 LifeStyles Front Desk: (425) 861-6258 or 2020Lifestyles@2020Lifestyles.com. For questions or concerns regarding your menu, please email your dietitian directly. Outside of normal business hours and on weekends please email foodchallenge@proclub.com for assistance.

Vegan Van. Shake + Berries + PB

Metabolic Choc. Shake + Berries + PB

Metabolic Van. Shake + Berries + PB

Egg White Salad Side

Tarragon Chicken Salad Side