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:
Pregnant/Nursing:
Height:
Age:
Important:
This Needs to be inches I.E. 66 NOT 5.6, 5'6', etc. When
English is checked and CM not Meters when Metric is checked.
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:
Activity Level
Check
the appropriate activity level that most closely approximates your
lifestyle. Examples: Activity level:
Body Weight
Present
Weight: Desired Weight:
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
3.0
lbs/Kg
Body Weight Charts for Women
Body Weight Charts for Men
Resting Heart Rate 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
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 Chart for Women and
Men
Daily Exercise Calorie Expenditure Goals
Exercise
Calorie Goal -
Monday:
Exercise
Calorie Goal -
Tuesday:
Exercise
Calorie Goal -
Wednesday:
Exercise
Calorie Goal -
Thursday:
Exercise
Calorie Goal -
Friday:
Exercise
Calorie Goal -
Saturday:
Exercise
Calorie Goal -
Sunday:
Exercise Calorie Expenditures Sorted by Activity
Exercise Calorie Expenditures Sorted by Activity
PCF Ratio Goal
If
you aren't sure what your ratio should be, leave them blank... our
Registered Dietitians will recommendpercentage
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
This
selection is optional. Please select the option that most closely
describes your goal:
Peak Body Weight
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.
Medical Conditions
Please
select as many as apply:
Comments and Additional Information
Please
enter additional information you feel is important to consider in your
personal assessment.
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