24Sculpt - weight loss nutrition plans

1
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6
Phone Number* This field is required.
Please enter a valid phone number.
7
Date of Birth* This field is required.Please fill in the date that you were born.
Date
Month
Day
Year
8
What is your weight and height?* This field is required.
9
Are you an existing 24sculpt.com patient?* This field is required.
YESNO
10
Thank you for continuing to use 24Sculpt for your medical weight loss needs. Although you are a returning patient, we have a few questions to ask to make sure that nothing has changed since your last visit.
11
How would you categorize your current weight?* This field is required.
Underweight (BMI below 18.5)
Healthy weight (BMI between 18.5 and 24.9)
BMI between 27 and 29.9
Obese (BMI between 30 and 39.9)
Morbidly obese (BMI above 40)
Unsure
12
Select your goal of weight loss treatment* This field is required.
Improve quality of life
Treat and reverse the complications of obesity
Prevent the complications of obesity
13
How many pounds would you like to lose in the next 3 months?* This field is required.Enter a number
Enter number
14
What is your waist size/circumference in inches?* This field is required.Type a number in inches
Inches
15
Weight Reduction & Safety Disclosure* This field is required.All fields are required to be checked.
16
Please upload a full body (head to toe) image of yourself. (Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Which of these conditions do you currently have or have had in the past?* This field is required.
None of the conditions below
Liver Disease or Kidney Disease
Gastroparesis
Pancreatitis
Hypoglycemia (low glucose)
18
Which of these weight loss measures have you tried?* This field is required.
Weight loss exercises
Diet
Portion control and calorie count
Behavior therapy by a trained personnel
Weight loss supplements
Weight loss Apps
19
Have you been evaluated or treated for weight loss by a doctor?* This field is required.
YESNO
20
Briefly describe your previous encounter with the doctor, including previous treatments.* This field is required.Include previous treatments
Huge
Large
Normal
Small
Ok
Ok
21
Which of these weight loss interventions have you explored in the past?* This field is required.
Prescription medication for weight loss
Liposuction
Bariatric surgery
Acupuncture
Other surgical interventions
Other interventions
None of the above medical interventions
22
Is there any information you would like to share with your medical provider today? (Optional)
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Large
Normal
Small
Ok
Ok
23
Select the underlying medical conditions you have currently or have had in the past.* This field is required.
None, I do NOT have any chronic medical or psychiatric conditions
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other condition
24
Type of heart disease* This field is required.
Coronary Artery Disease (CAD) or heart attack
Heart Valve Disease
Arrhythmias or abnormal heartbeat
Heart Failure or CHF
Congenital Heart Disease
Cardiomyopathy (Heart Muscle Disease)
Pericardial Disease
Other heart diseases
25
How stable or controlled is your diabetes?* This field is required.
Well controlled (Glucose below 150 or HbA1c less than 8)
Somewhat controlled (Glucose below 200 or HbA1c less than 9)
Uncontrolled Diabetes (Glucose over 200 or HbA1c over 9)
26
Select applicable psychiatric conditions* This field is required.
Depression
Anxiety
Panic Disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other psychiatric conditions
27
What's your average blood pressure reading?* This field is required.
Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)
28
Are you currently taking any medication?* This field is required.
YESNO
29
Enter medication names* This field is required.
Huge
Large
Normal
Small
Ok
Ok
30
What is your biological sex (gender at birth)?* This field is required.
FemaleMale
31
Are you currently pregnant?* This field is required.
YESNO
32
Select applicable surgical history.* This field is required.
None, No surgical past
Appendectomy
Breast augmentation
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Other surgery
33
List any other past surgeries.* This field is required.
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Large
Normal
Small
Ok
Ok
34
Which of these social histories applies to you?* This field is required.
I drink coffee or caffeinated drinks regularly
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Marijuana use
Opioid Addiction
Alcohol Addiction
Recreational or illicit drug use
None of the above
35
When was your last in-person visit to the doctor?-* This field is required.
In the last 3 months
In the last 3 to 6 months
In the last 6 to 12 months
Over a year ago
I have NEVER sees a doctor in-person
36
Do you currently keep track of your average daily caloric intake?
YESNO
37
Please enter your average daily caloric intake over the past 1-2 weeks.
38
Do you know your average daily intake of grams or calories of carbohydrates, grams or calories of protein, and grams or calories of fat?
YESNO
39
Please enter the amount of carbohydrates protein and fats that you eat on average on two weekdays and one weekend day.* This field is required.
Grams
Calories
Carbohydrates - Week day 1
Row 0, Column 0
Row 0, Column 1
Protein - Week day 1
Row 1, Column 0
Row 1, Column 1
Fat - Week day 1
Row 2, Column 0
Row 2, Column 1
Carbohydrates – Week day 2
Row 3, Column 0
Row 3, Column 1
Proteins – Week day 2
Row 4, Column 0
Row 4, Column 1
Fat – Week day 2
Row 5, Column 0
Row 5, Column 1
Carbohydrates – Weekend
Row 6, Column 0
Row 6, Column 1
Protein - Weekend
Row 7, Column 0
Row 7, Column 1
Fat - Weekend
Row 8, Column 0
Row 8, Column 1
Carbohydrates - Week day 1
Protein - Week day 1
Fat - Week day 1
Carbohydrates – Week day 2
Proteins – Week day 2
Fat – Week day 2
Carbohydrates – Weekend
Protein - Weekend
Fat - Weekend
Grams
Row 0, Column 0
Calories
Row 0, Column 1
Grams
Row 1, Column 0
Calories
Row 1, Column 1
Grams
Row 2, Column 0
Calories
Row 2, Column 1
Grams
Row 3, Column 0
Calories
Row 3, Column 1
Grams
Row 4, Column 0
Calories
Row 4, Column 1
Grams
Row 5, Column 0
Calories
Row 5, Column 1
Grams
Row 6, Column 0
Calories
Row 6, Column 1
Grams
Row 7, Column 0
Calories
Row 7, Column 1
Grams
Row 8, Column 0
Calories
Row 8, Column 1
1 of 9
40
Because you do not currently know the average daily chloric intake that you consume, we need to do a nutritional analysis using a dietary log in the following questions. Please answer for two weekdays what you normally consume for breakfast, lunch and dinner and any snacks and for one weekend day, what you normally consume for breakfast lunch and dinner and any snacks. Your nutritional plan will be built off of the information that you enter in this log, so please try to be as accurate as possible.
41
For week day 1, please enter the foods or drinks that you consume during breakfast and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat breakfast, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Breakfast
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Breakfast
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Breakfast
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Breakfast
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Breakfast
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
42
For week day 1, please enter the foods or drinks that you consume during lunch and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat lunch, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Lunch
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Lunch
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Lunch
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Lunch
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Lunch
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Lunch
Lunch
Lunch
Lunch
Lunch
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
43
For week day 1, please enter the foods or drinks that you consume during dinner and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat dinner, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Dinner
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Dinner
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Dinner
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Dinner
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Dinner
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Dinner
Dinner
Dinner
Dinner
Dinner
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
44
For week day 1, please enter the foods or drinks that you consume during snacks and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat snacks, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Snack
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Snack
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Snack
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Snack
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Snack
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Snack
Snack
Snack
Snack
Snack
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
45
For week day 2, please enter the foods or drinks that you consume during breakfast and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat breakfast, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Breakfast
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Breakfast
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Breakfast
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Breakfast
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Breakfast
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
46
For week day 2, please enter the foods or drinks that you consume during lunch and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat lunch, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Lunch
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Lunch
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Lunch
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Lunch
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Lunch
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Lunch
Lunch
Lunch
Lunch
Lunch
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
47
For week day 2, please enter the foods or drinks that you consume during dinner and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat dinner, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Dinner
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Dinner
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Dinner
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Dinner
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Dinner
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Dinner
Dinner
Dinner
Dinner
Dinner
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
48
For week day 2, please enter the foods or drinks that you consume during snacks and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat snacks, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Snack
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Snack
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Snack
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Snack
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Snack
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Snack
Snack
Snack
Snack
Snack
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
49
For a weekend day, please enter the foods or drinks that you consume during breakfast and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat breakfast, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Breakfast
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Breakfast
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Breakfast
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Breakfast
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Breakfast
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
50
For a weekend day, please enter the foods or drinks that you consume during lunch and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat lunch, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Lunch
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Lunch
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Lunch
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Lunch
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Lunch
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Lunch
Lunch
Lunch
Lunch
Lunch
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
51
For a weekend day, please enter the foods or drinks that you consume during dinner and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat dinner, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Dinner
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Dinner
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Dinner
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Dinner
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Dinner
Row 4, Column 0
1
2
3
4
5
Row 4, Column 1
3
6
8
10
12
Row 4, Column 2
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
Dinner
Dinner
Dinner
Dinner
Dinner
Food
Row 0, Column 0
Number of items
1
2
3
4
5
Row 0, Column 1
Ounces
3
6
8
10
12
Row 0, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Food
Row 1, Column 0
Number of items
1
2
3
4
5
Row 1, Column 1
Ounces
3
6
8
10
12
Row 1, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Food
Row 2, Column 0
Number of items
1
2
3
4
5
Row 2, Column 1
Ounces
3
6
8
10
12
Row 2, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Food
Row 3, Column 0
Number of items
1
2
3
4
5
Row 3, Column 1
Ounces
3
6
8
10
12
Row 3, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 3, Column 3
Food
Row 4, Column 0
Number of items
1
2
3
4
5
Row 4, Column 1
Ounces
3
6
8
10
12
Row 4, Column 2
Grams
4
6
8
10
12
14
20
30
40
50
Row 4, Column 3
1 of 5
52
For a weekend day, please enter the foods or drinks that you consume during snacks and the quantities of each item as either the number of items, the ounces, or grams. If you do not eat snacks, enter none in the first box.* This field is required.
Food
Number of items
Ounces
Grams
Snack
Row 0, Column 0
1
2
3
4
5
Row 0, Column 1
3
6
8
10
12
Row 0, Column 2
4
6
8
10
12
14
20
30
40
50
Row 0, Column 3
Snack
Row 1, Column 0
1
2
3
4
5
Row 1, Column 1
3
6
8
10
12
Row 1, Column 2
4
6
8
10
12
14
20
30
40
50
Row 1, Column 3
Snack
Row 2, Column 0
1
2
3
4
5
Row 2, Column 1
3
6
8
10
12
Row 2, Column 2
4
6
8
10
12
14
20
30
40
50
Row 2, Column 3
Snack
Row 3, Column 0
1
2
3
4
5
Row 3, Column 1
3
6
8
10
12
Row 3, Column 2
4
6
8
10
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53
I understand that 24Sculpt will perform a nutrition analysis and prescribe a 1 month or 3 month dietary weight loss plan. I will need to return in 3 weeks or 2.5 months for a follow up visit for re-evaluation and an updated plan.* This field is required.
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24Sculpt does not accept insurance.* This field is required.
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Nutrition analysis with a 1 month weight loss nutrition plan + telehealth appointmentYou will receive a 1 month nutrition plan based on your current dietary caloric and macronutrient intake. Your nutrition plan will be delivered directly to your email address after our staff Medical Doctor and Nutritionist have performed your dietary analysis and patient-specific plan that takes into account any medical comorbities you a may have. In addition, you will charged a 1 time fee for a telehealth visit. The total for the dietary analysis + 1 month nutrition plan + the 1 time telehealth visit is $29.99. Should you like to continue your prescription after 1 month, you will need to complete another telehealth visit and purchase own updated nutrition plan at that time. Please allow 2-3 days for delivery of your plan following review of our Medical Doctor and Nutritionist.
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Nutrition analysis with a 3 month weight loss nutrition plan + telehealth appointmentYou will receive a 3 month nutrition plan based on your current dietary caloric and macronutrient intake. Your nutrition plan will be delivered directly to your email address after our staff Medical Doctor and Nutritionist have performed your dietary analysis and patient-specific plan that takes into account any medical comorbities you a may have. In addition, you will charged a 1 time fee for a telehealth visit. The total for the dietary analysis + 3 month nutrition plan + the one time telehealth visit is $17.99 / month. Should you like to continue your prescription after 1 month, you will need to complete another telehealth visit and purchase own updated nutrition plan at that time. Please allow 2-3 days for delivery of your plan following review of our Medical Doctor and Nutritionist.
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