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Nutrition Analysis Questionnaire

This nutrition questionnaire is used to analyze your current calorie needs along with the amount of carbohydrate, protein and fat that is right for you. A one day meal plan will also be included as an example. It can be used by itself or in combination with a nutrition assessment or weight loss/diabetic package. Please see the services page for more information on services The Healthier You offers. You will receive the results via e-mail so Please allow 3-7 days to receive your results. Due to the effort involved in constructing this report this purchase is non refundable and does not come with a money back guarantee.

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: 0.00.10.20.30.40.50.60.70.80.91.01.11.21.31.41.51.61.71.81.92.02.53.0lbs/Kg

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.