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It’s easy to start The Healthy Way Online Weight Loss Program and begin lose weight fast!

Upon Signing up for our Online Weight Loss Program you will:

Begin the Metabolic Adjustment Cleansing Diet
(you will receive the diet and get instructions online)
Have a phone interview to customize your individual weight loss program
Discuss your blood sugar risk assessment
Determine your Basal Metabolic Rate (BMR)

PLEASE NOTE: The Online Program is NOT available to those who reside within a 25 mile radius of a Healthy Way center.

Registration Form

Product Name*
Prices shown includes a one-time $149 registration fee to design your personalized program, which includes evaluation/review of medical, nutritional, personal and lifestyle histories; starter kit of initial products and written materials; analysis of Basal Metabolic Rate (BMR); and recommendations of goal weight/body fat percentage and exercise.
Total
$0.00
Prices includes shipping and handling.
Personal Info
Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Occupation
Referred By
Doctor's Name
When did you begin to gain excess weight?
What factors do you feel have contributed to your weight gain?
What other methods of losing weight have you tried? Please specify:
When were you most satisfied with your weight?
Why is it important for you to lose weight now?
What foods or situations do you find problematic?
Do you have a support system that will aid you in your weight loss?
What is your current form of exercise?
Are you willing to follow through with a maintenance program?
Health History
*With a Doctor's prescription, the Healthy Way Program is tax deductible. Contact your physician.
Are you pregnant?*
- Yes
- No
Are you a nursing mother?*
- Yes
- No
*Do you have diabetes mellitus?*
- Yes
- No
*Diet controlled?*
- Yes
- No
*Oral medication?*
- Yes
- No
*Insulin shots?*
- Yes
- No
Are you hypoglycemic?*
- Yes
- No
*Have you had cancer?*
- Yes
- No
*Are you being treated now?*
- Yes
- No
*Do you have renal disease/insufficiency?*
- Yes
- No
*Have you had kidney stones?*
- Yes
- No
*Do you have anorexia or bulimia?*
- Yes
- No
*Have you had gall stones?*
- Yes
- No
Have you had any specialized surgery?*
- Yes
- No
*Please explain:*
Do you have any food allergies?*
- Yes
- No
*Are you 50 pounds or more overweight?*
- Yes
- No
Do you have any other medical problems for which you are receiving treatment?*
- Yes
- No
Has your physician recommended that you lose weight?*
- Yes
- No
*Do you presently have high blood pressure (hypertension)?*
- Yes
- No
*Do you take hypertensive medication?*
- Yes
- No
*Please list any medications you are taking at this time:*
Do you have any gastrointestinal problems or constipation?*
- Yes
- No
*Do you have heart disease?*
- Yes
- No
Do you have a history of headaches?*
- Yes
- No
Do you have any other health concerns?*
- Yes
- No
Choose your Activity Level:*
Height*
Weight*
Wrist Measurement*
Nutritional/Metabolic Evaluation
The first 12 questions represent the classic symptoms of fluctuating blood sugar, and referred to as hypoglycemia, low blood sugar or glucose intolerance. A score of 4 or more classic symptoms (*) or an overall score of 6 or more "frequently" items suggests that you are a candidate for The Healthy Way Metabolic Adjustment Program. This program focuses on the revolutionary concept of blood sugar stabilization and hormonal balance to create long term success. We have the answers for you! Added indicators of blood sugar instability includes: limited physical activity, being 50 pounds or more overweight, a personal and family history of hypertension, stroke, diabetes, heart disease or female reproductive disorders. Frequent cold extremities, consumption of package/processed foods and high stress levels are also factors.
Do you think of food (sense of hunger) more than you feel comfortable with?
- Occasionally to Frequently
- Rarely to Not at All
Do you experience light-headedness?
- Occasionally to Frequently
- Rarely to Not at All
Do you have cravings for sweets or carbohydrates?
- Occasionally to Frequently
- Rarely to Not at All
Do you have a drop in energy (body feels like "lead bricks") especially mid-day?
- Occasionally to Frequently
- Rarely to Not at All
Do you have tunnel or blurred vision?
- Occasionally to Frequently
- Rarely to Not at All
Do you get headaches?
- Occasionally to Frequently
- Rarely to Not at All
Do you have difficulty in concentrating?
- Occasionally to Frequently
- Rarely to Not at All
Do you have indigestion or gas?
- Occasionally to Frequently
- Rarely to Not at All
Do you experience rapid weight gain or have difficulty controlling weight?
- Occasionally to Frequently
- Rarely to Not at All
Do you experience out-of-control or compulsive behavior with food, especially sweets are starches?
- Occasionally to Frequently
- Rarely to Not at All
Do you experience mood swings or depression?
- Occasionally to Frequently
- Rarely to Not at All
Do you have high cholesterol or triglycerides readings?
- Occasionally to Frequently
- Rarely to Not at All
Do you have experience hunger between meals or snacking late at night?
- Occasionally to Frequently
- Rarely to Not at All
Do you have cold extremities?
- Occasionally to Frequently
- Rarely to Not at All
Do you consume processed or packaged foods?
- Occasionally to Frequently
- Rarely to Not at All
Do you skip breakfast and/or eat meal irregularly?
- Occasionally to Frequently
- Rarely to Not at All
Do you drink 2 or more cups of coffee, tea, sodas or artificially sweetened beverages per day?
- Occasionally to Frequently
- Rarely to Not at All
Do you consume alcohol more than once per week?
- Occasionally to Frequently
- Rarely to Not at All
Do your snacks generally consist of fruit, crackers, chips, cookies or candy?/
- Occasionally to Frequently
- Rarely to Not at All
Do you experience PMS/menopausal symptoms?
- Occasionally to Frequently
- Rarely to Not at All
Do you take birth control pills or female hormone replacement therapy?
- Occasionally to Frequently
- Rarely to Not at All
Is bread, pasta, or other starch, fruit or sweets usually included in one or more meals per day?
- Occasionally to Frequently
- Rarely to Not at All
Do you smoke one or more packs of cigarettes per day?
- Occasionally to Frequently
- Rarely to Not at All
Do you experience stress at both home and work?
- Occasionally to Frequently
- Rarely to Not at All

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