Thank you for choosing Master Diet.
Please make sure you have read and understand our User Agreement

Please provide us with the following information so we can customize your diet.
This process will only take a few minutes.
Please answer all questions as accurately as possible for the best results.
All information is private and will not be used for any other purpose.

 

Title              First Name         MI       Last Name
      
Address:   
         
City:       State/Prov: Zip:
                                   Country:  
Gender:                       Age:        (in years)
Home Phone:      Date of Birth:          (mm/dd/yy)
Work Phone:     Height:             in.(=cm X .359)
Fax:           Present Wt:          lbs(=kg X .456)
                                Desired Wt:          lbs (=kg X .456)
E-Mail Add.:  
Stomach Measurement* (in inches): (cm X .359 = in.)
* For stomach measurements, please measure your stomach at it's greatest circumfrence,
   typically across or near the navel (not where your belt is).

What Type of Job Do You Have:           
Hours of Exercise per Week Currently:    
How Intense is the Exercise:           
Hours of Exercise per week during Diet:  
How Intense will this exercise Be:      
Are you Pregnant (Women Only):         
Are you Nursing (Lactating- Women Only): 

What is Your Doctor's Name?                              
Address Line 1:                              
Address Line 2:                              
City:                              
State:                              
Zip:                              
Phone:                              
Fax:                              

Are you suffering from any conditions such as high blood pressure, diabetes, or heart disease? If so, please indicate the condition, the severity, and whether or not you are taking medication for the condition.

Condition: Severity: Medication?

Condition: Severity: Medication?

Condition: Severity: Medication?

Now please select a user name and password. User names and passwords can be composed of letters and/or numbers and must be at least 3 sharacters long each. If the users name you select is already in use, you will be prompted to choose another one.

Desired User Name:     Desired Password:    
Please verify your password by typing it in this box: