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Follow Up

Please complete and submit the form below.  A Barix Nutritionist will contact you via phone or email to follow-up.  You may also call 734-547-1274 or 800-282-0066 extension 1274 if you have questions at anytime.

First Name
 * required
 
Last Name
 * required
 
Preferred Method For Contact:
 
Daytime Phone
Email
I Do Not Want To Be Contacted
 
Daytime Phone (XXX-XXX-XXXX)
 
Email Address
 
Type of Surgery

Areas In Which You Would Like Help:

Changing Behavior
Developing New Coping Skills
Emotional Eating
Exercise
Food Choices
Grocery Shopping
Hunger Control
Meal Planning
Portion Control
Stress Reduction
Other
List amounts and types of vitamins taken:
 
Protein Goal
 
Enter the foods and beverages eaten
yesterday-include amounts:
 
List exercise type, frequency & length
of time:
 
List any stessors or changes that have
impacted your weight:

                                                                                                                                                                                                                                                                                                                                    

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