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Shirley Chan Accredited Practising Dietitian
Improving health one bite at a time.

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Meal Plan Order Form

First name*

Last name*

Email*

Age*

Mobile number (optional)

What is your goal? (To eat healthier, less takeaway, anti-inflammatory diet)

Height (cm)*

Weight (kg)*

Level of physical activity*

Little or No Exercise - sitting down most of the day

Light physical activity or sports 1–3 days/week Includes daily activities like walking, house chores

Moderate physical activity - 3–5 days/week of exercise e.g. gym sessions, running, cycling, brisk walking

Very Active - Exercise 6-7 days/week in during work e.g. builder or athletes training most days of the week

List all food allergies and intolerances. These food will be excluded in your meal plan. Write 'nil' if no allergies or no intolerances. *

How many main meals per day would you like. Default is 3 main meals a day.

How many snacks per day would you like. Default is 2 snacks a day.

How much time do you have for cooking?

Quick and easy. I have around 15 minutes to cook

Slightly more involved. I can spend around 30 minutes to cook

Would you take leftover for lunch?

Yes

Type of meals I like

Curries

Salads

Stir fries

Seafood

Other meals that I like are:

Anything else? e.g. Days in the office, cooked breakfast for weekend etc. More you tell us about your eating habit and preference, the more personalised your meal plan would be.

Consent

I understand that this personalised meal plan service is intended for general health and wellness purposes. It is not a substitute for professional medical and nutrition advice, assessment, diagnosis, or treatment.

I have read, understand and agree with the Service Terms and Condition, and Disclaimer.

I confirm the information provided in this form is true, accurate and complete.

Choose Meal plan service type*

7 days meal plan$120

14 days meal plan$190

SC Nutrition ABN 41 009 192 602

Medicare Provider Number 2567745X

P: 0491 681 195

F: 02 8530 7905

E: info@shirleychandietitian.com.au

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