Wellness























Contact Us

Interested in our Nutrition Services?

We offer a wide variety of scheduling options to meet your needs.
Please fill out the form below the Nutrition Coach will contact you.

Please note that fields marked with an * are required.

* Name: Age:

Gender: Male Female

* Phone Number: E-mail:

What are your main nutrition interests?

Healthful Eating Eating Out Healthfully
Weight Management Disease Prevention/Wellness
Managing Family Meals Sports Nutrition
Other

Have you ever tried (or are currently following) any diet plans?
Yes No

Do you frequently skip meals?
Yes No

Do you feel tired and listless at certain times of the day?
Yes No

How often do you eat meals out (sit-down, fast food or take-out)?
times per week

List any vitamins, minerals or other supplements you regularly take.

Has your doctor told you that you have:

High Blood Pressure High Triglycerides
Diabetes Heart Disease
High Cholesterol

Would you like to lose weight as part of your fitness goals?
Yes No

Which of our programs best suits your needs at this time?

Eight Weeks to Success Stay on Your Way
Metabolism Assessment The Power Pack
Nutrition Counseling Nutrition Consultation
Supermarket Tours Not Sure

Do you have a preferred counseling style?
No-nonsense Patient/nurturing   Other:

Have you used your Nutrition Fit-Pass yet?
Yes No

Are you a new member?
Yes No

copyright 2007 © acac fitness and wellness centers - 500 Albemarle Square, Charlottesville VA 22901 - 434-978-3800
111 Monticello Ave., Charlottesville VA 22902 - 434-984-3800 / 200 Four Seasons Drive, Charlottesville VA 22901 - 434-978-PLAY