Initial Assessment Questionnaire

Please fill in all the required information (in pink). After submitting this questionnaire your results will be emailed to you as soon as it is complete. If you need want to get started sooner, please contact me directly via phone or using our contact page

Required information.

Optional information.

Contact Information

First Name: MI:Last:
Address Line 1:
Address Line 2:
City: State:Postal Code:
Country: Email:Phone:

Unit of Measure

Select the unit of measure you wish to use for height and weight entries:

English (inches, lbs)   Metric (cm, Kg)

Personal Information

Sex: Female Male

Pregnant/Nursing: n/aPregnant Nursing

Height: inches/cm

Age:

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 MediumLarge

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: SedentaryModerately Active Very Active

Body Weight

Present Weight: lbs/Kg     Desired Weight: lbs/Kg

Desired loss/gain per week: 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.5 3.0lbs/Kg

Body Weight Charts for Women

Body Weight Charts for Men

Resting Heart Rate - Optional

Resting Heart Rate:

Please enter your heart rate, measured first thing in the morning before you get out of bed.

Percentage Body Fat Composition Values - Optional

Present % Body Fat Content:     Desired % Body Fat Content:

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.

Body Fat Chart for Women and Men

Daily Exercise Calorie Expenditure Goals - Optional

Exercise Calorie Goal - Monday:  

    calories

Exercise Calorie Goal - Tuesday:  

    calories

Exercise Calorie Goal - Wednesday:  

    calories

Exercise Calorie Goal - Thursday:  

    calories

Exercise Calorie Goal - Friday:  

    calories    

Exercise Calorie Goal - Saturday:  

    calories

Exercise Calorie Goal - Sunday:  

    calories

Exercise Calorie Expenditures Sorted by Activity     Exercise Calorie Expenditures Sorted by Intensity

PCF Ratio Goal - Optional

If you aren't sure what your ratio should be, leave them blank... we will recommend
one for you. Enter your goal for these three variables as a percentage of your total daily calorie intake:

% Protein Calories: % Carbohydrate Calories: % Fat Calories:

(These three percentages must equal 100%. If they don't, we'll enter values for you.)

Personal Goal - Optional

This selection is optional. Please select the option that most closely describes your goal:
Lose Weight Maintain Weight Gain Weight Increase Athletic Performance

Peak Body Weight - Optional

What is the most you ever weighed?:  

lbs/Kg

When did you weigh this amount?:  

This is my present weight. Within the past three months. Within the past six months. Within the past 12 months. Within the past two years. Within the past five years. More than five years ago.

Comments and Additional Information - Optional

Please enter additional information you feel is important to consider in your personal assessment.