Our Most Frequently Requested Programs:

Weight Management
Low Sugar
Low Cholesterol
Low Sodium
Dairy Free
Gluten Free
Wheat Free
Soy Free
Pain Management
Sports Nutrition

Have a special need not listed?
Please Contact Us

Rachel Lerner, CNC

" Every body is unique."

Whatever your health goals are, Personal Web Nutrition has a custom food plan or program for you.

We can even help you figure out exactly what your goals should be if you are unsure.

E: info@personalwebnutrition.com
P: 917-885-0052

Nutrition Assessment Form

Contact Information *All fields marked with a are required:**
First * and Last Name *
E - Mail * (username@domain.com)
Address 1 *
Address 2
City *
State / Zip (#####) *	Services are currently NOT available in the following states: AL, AR, DC, FL, GA, LA, MD, MT, NM, NC, ND, OH, TN and WV
Telephone (##########)*

Personal Information
Age	18-25 26-32 33-40 41-50 51+
Gender	Male Female

Nutrition History (or Health Information)
Do you currently have any health issues? *
List any food allergies, intolerances or sensitivities please be specific *
How many nights per week do you eat out ?	0 1 2 3 4 5 6 7
Do you consume any alcohol ?	YES NO
How often do you consume alcohol?

Physical Fitness
Do you exercise? *	YES NO
Please note type of exercise frequency and duration of exercise

Other Information
What goals would you like Personal Web Nutrition to help you accomplish?

Other Comments

I would like to be included in Personal Web Nutrition's periodic e-mails: YES

Terms and Conditions	TERMS AND CONDITIONS These Terms and Conditions, when accepted by you, shall be a contract between you and Healthy Living by Rachel, Inc. dba Personal Web Nutrition ("Personal Web Nutrition" or "we") governing services provided by Personal Web Nutrition to you. Personal Web Nutrition offers such services contingent upon your acceptance of these Terms and Conditions. These Terms and Conditions expressly include the Legal Disclaimer set forth on this website, which disclaimer is incorporated herein as if fully set forth. Before continuing the subscription application, you must review these Terms and Conditions, including the incorporated Legal Disclaimer, in full and agree to abide by same. BY CLICKING THE "I AGREE" BUTTON BELOW, YOU CERTIFY THAT YOU ARE OVER THE AGE OF EIGHTEEN AND HAVE LEGAL AUTHORITY TO ENTER INTO THIS CONTRACT. YOU FURTHER CERTIFY THAT YOU HAVE READ THESE TERMS AND CONDITIONS AND AGREE TO BE BOUND BY SAME. After you have clicked the "I AGREE" button, you will be permitted to complete your subscription. Ownership. The website www.personalwebnutrition.com, its contents and all communications and materials we provide via this website are the property of Healthy Living by Rachel dba Personal Web Nutrition. Information provided to you as a subscriber is intended for your sole, non-commercial use. You are expressly prohibited from using any of the information contained on this website or provided to you as a subscriber for any commercial use. Consult Your Physician. By continuing with the subscription you acknowledge that this site and the services offered by Personal Web Nutrition are not intended to be and do not constitute medical advice. You should always consult your healthcare provider before embarking on any dietary change or exercise regime. Privacy Statement. All information requested to be provided by you is for the sole purpose of providing services to you and collecting payment for such services. Personal Web Nutrition will not sell your personally identifiable information to anyone nor use any of this information for any purpose other than for the purposes of facilitating the electronic payment via a third-party contractor and purposes of providing personal services to you and, if necessary, to enforce these Terms and Conditions. Also, certain automatic recording of information by our web hosting service may occur, including information such as your IP address, cookie information and the pages of this website which you have visited. Personal Web Nutrition will make commercially reasonable efforts to maintain the confidentiality of personally identifiable information provided by you. However, you acknowledge that it may be necessary to disclose such information or portions thereof when required by law, when subject to a legal or administrative order or when we have a good faith belief that such action is necessary to comply with legal requirements or if legal process is served on Personal Web Nutrition. Security. Personal Web Nutrition utilizes a third-party web hosting company. Although precautions are taken to secure users' information, Personal Web Nutrition cannot guarantee and hereby disclaims any liability in relation to, maintenance of such security. Payment. By continuing with your subscription you represent that you are acting on your own behalf and that all information you provide is truthful and accurate. You must ensure that all of your information is entered correctly and that sufficient sums are available on your credit card to cover the transaction. You must keep all billing information current including your billing address and the expiration date of your credit card. You may change your payment method or update billing information by sending an e-mail to info@personalwebnutrition.com. PERSONAL WEB NUTRITION IS NOT LIABLE FOR AND HEREBY DISCLAIMS ANY LIABILITY RELATING TO, PROCESSING OF YOUR CREDIT CARD TRANSACTION FOR PAYMENT OF SERVICE FEES. Personal Web Nutrition contracts with a third-party payment processor for the convenience of those choosing to utilize credit card payment. Personal Web Nutrition is not responsible for the actions of such third-party. Cancellation and Refund Policy. Personal Web Nutrition reserves the right to cease offering services at any time. You have the right to cancel any subscription or request for services at any time. To cancel services, e-mail info@personalwebnutrition.com with a subject heading of "Request for Cancellation of Services" and a description of the services which you choose to cancel or in writing as set forth in the "Notices" provision, below. You will receive an e-mail confirming receipt of your cancellation notice. Cancellation will be effective upon confirmation. Certain service offers may not be subject to a refund. Please consult the service offer under which you requested services for the terms of same. Cancellation will not alter or obviate your obligation to pay for all charges already made to your billing account nor for services provided prior to the date of cancellation. Trial Offers. Should you request services under a service offer which includes a trial or other similar free period of service, you must cancel the service by the end of the trial period to avoid incurring charges. If you do not cancel the service, your request for services will be automatically renewed under the then current pricing. In the absence of a valid cancellation, you authorize us to charge your credit card for such continued services. Price Changes. Pricing for certain services is charged on a periodic basis as set forth within this website. Should pricing change, new prices will appear in the service offers on this website and you will be notified by e-mail. Unless you cancel such services within thirty (30) days of the date of such e-mail notification, you hereby authorize Personal Web Nutrition to charge your credit card at the new price. Notices. Any notices to be provided by Personal Web Nutrition to you shall be provided by e-mail addressed to the e-mail address you provide in connection with your subscription following your agreement to these Terms and Conditions. Any notice by you shall be provided in writing, via mail to "Personal Web Nutrition, 17 Maple Drive, Great Neck, New York 11021." Prohibited Activities. You hereby agree that, in connection with your use of this website and the services you are requesting from Personal Web Nutrition, you will not: -transmit any content to Personal Web Nutrition or via this website that is in violation of law or which may infringe on any third-party's right to privacy or intellectual property or other rights; -impersonate any other person or entity or falsely identify or otherwise misrepresent yourself; -take any action which threatens the integrity of this website and/or its availability to other users; -violate any applicable law or regulation; -reproduce, publish, copy, sell or otherwise exploit for commercial use any portion of this website or any information provided to you by Personal Web Nutrition. -otherwise use the services provided on or via this website for any purpose which is not permitted by these Terms and Conditions. Indemnification. You agree to indemnify and hold harmless Personal Web Nutrition, its employees, officers and agents, from any and all claims arising from your request for services and use of the information and services provided in response to your request for services. Modification. Personal Web Nutrition reserves the right to modify these Terms and Conditions from time to time. You therefore should periodically review these Terms and Conditions for any changes. Miscellaneous. These Terms and Conditions constitute the entire agreement between you and Personal Web Nutrition relating to the subject matter hereof and supersedes any prior agreements or representations. These Terms and Conditions may be altered only as set forth in the "Modification" and "Price Changes" provisions, above, or in a single, separate writing signed by both you and Personal Web Nutrition. Failure of Personal Web Nutrition to exercise and enforce any right or provision of these Terms and Conditions or its delay in so enforcing, will not be a waiver of such right or provision. These Terms and Conditions are governed by the laws of the State of New York and the courts in the State of New York have sole and exclusive jurisdiction over any dispute related to these Terms and Conditions. If any provision of these Terms and Conditions is held to be illegal, unenforceable or void for any reason, then that provision shall be of no force and effect; however, that shall have no effect upon the enforceability of any other provision of these Terms and Conditions. No non-party shall be a third-party beneficiary under these Terms and Conditions. Your rights and obligations under these Terms and Conditions belong to you and may not be assigned by you to any third-party. Reservation of Rights. Personal Web Nutrition reserves the right to deny any request for services for any reason. Unless and until Personal Web Nutrition accepts your request for services and receives payment therefore, Personal Web Nutrition shall have no obligation to provide such services. Should Personal Web nutrition provide requested services to you prior to payment by you, you will be liable for payment for such services. Any violation by you of these Terms and Conditions will entitle Personal Web Nutrition to immediately terminate these Terms and Conditions and your continued access to services via this website. Unfortunately, Personal Web Nutrition services are not available to residents of the states of Arizona, Arkansas, District of Columbia, Florida, Georgia, Louisiana, Maryland, Montana, New Mexico, North Carolina, North Dakota, Ohio, Tennessee and West Virginia, as well as residents of countries other than the United States. I have read and accept the terms & conditions *

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