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Contact Information |
First Name: MI: Last: 
Address Line 1:
Address Line 2:
City: State: Postal Code:
Country: Email: Phone: |
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Unit of Measure |
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Select the unit of measure you wish to use for height and weight entries: |
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English (inches, lbs) Metric (cm, Kg) |
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Personal Information |
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Sex: Female Male |
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Pregnant/Nursing: n/a Pregnant Nursing |
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Height: inches/cm |
Age: |
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Body Frame |
If you don't already know your body frame type, try this: place your thumb and middle finger around your wrist. If they overlap, enter "small." If they just touch, enter "medium." If they don't touch, enter "large."
Body Frame: Small Medium Large |
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Activity Level |
Check the appropriate activity level that most closely approximates your lifestyle. Examples:
Sedentary = working behind a PC. Moderately Active = waiting tables. Active = construction work.
Activity level: Sedentary Moderately Active Very Active
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Body Weight |
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Present Weight: lbs/Kg Desired Weight: lbs/Kg |
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Desired loss/gain per week: lbs/Kg |
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Body Weight Charts for Women |
Body Weight Charts for Men |
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Resting Heart Rate
Resting Heart Rate:
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Please enter your heart rate, measured first thing in the morning before you get out of bed. |
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Percentage Body Fat Composition Values |
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Present % Body Fat Content: Desired % Body Fat Content:
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Please enter both values if you want calculations to be based on your body fat content.
Body fat calculations will override any value you may have entered for Desired Weight. |
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Body Fat Chart for Women and Men |
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Daily Exercise Calorie Expenditure Goals |
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Exercise Calorie Goal - Monday: |
calories |
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Exercise Calorie Goal - Tuesday: |
calories |
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Exercise Calorie Goal - Wednesday: |
calories |
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Exercise Calorie Goal - Thursday: |
calories |
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Exercise Calorie Goal - Friday: |
calories |
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Exercise Calorie Goal - Saturday: |
calories |
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Exercise Calorie Goal - Sunday: |
calories |
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Exercise Calorie Expenditures Sorted by Activity Exercise Calorie Expenditures Sorted by Intensity |
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PCF Ratio Goal |
If you aren't sure what your ratio should be, leave them blank... our Registered Dietitians will recommend
one for you. Enter your goal for these three variables as a percentage of your total daily calorie intake: |
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% Protein Calories: % Carbohydrate Calories: % Fat Calories:
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(These three percentages must equal 100%. If they don't, we'll enter values for you.) |
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Personal Goal |
This selection is optional. Please select the option that most closely describes your goal:
Lose Weight Maintain Weight Gain Weight Increase Athletic Performance |
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Peak Body Weight |
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What is the most you ever weighed?: |
lbs/Kg |
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When did you weigh this amount?: |
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Medical Conditions |
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Please select as many as apply: |
Anemia
Asthma
Colitis
Diabetes
Gastric Reflux
Hypertension |
Hypoglycemia
Irritable Bowel Syndrome
Heart Disease
Hiatal Hernia
Liver Disease
Other (specify): |
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Comments and Additional Information |
Please enter additional information you feel is important to consider in your personal assessment.
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