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Initial Assessment Questionnaire
Free Initial Diabetic Diet Assessment Questionnaire
The first step in controlling blood glucose, Weight control and other health related nutrition issues is understanding
where you are now and where you want to set as a goal. This Nutrition assessment questionnaire will help you
understand what you need to do nutritionally to reach your goal.

When you click the submit button, our Diet Assessment questionnaire checks your entries and makes sure that all the
required fields are filled in. It also checks to make sure the email address is properly formatted. If something is amiss, a
message appears and directs you to the fields that need to be corrected. If everything is okay, this data is copied to a
flat-file (text-based) database on our server. It is only available to our Nutrition Consultants. None of the personal
information will be sold, given or in any other way be transferred  to a third party.
SEE OUR PRIVACY POLICY FOR MORE DETAILS

When this information is processed, NutriCoach will log you on as a client and generate your FREE NUTRITION
ASSESSMENT  REPORT. It will "know" 177 things about you. The contact information you provide will be automatically
placed into the Diabetic-Diet-Secrets.com Client Contact Manager.

Once you are logged on as a client, we'll  analyze your information and generate a detailed personalized multi-page Initial
Diet Assessment Report for you. This Diet Assessment Report will be emailed to you so be sure your email is entered
accurately.  It typically takes 24 - 48 hours for for your information to be analyzed and an email sent with your FREE NUTRITION
ASSESSMENT REPORT. 
 
Please complete the following form. Take your time and be as accurate as possible. Your NUTRITION ASSESSMENT REPORT
is highly customized based on the information you provide. If an accurate report is important to you, it is important to carefully
read the form and enter accurate information. It is not a generic pre-printed form all values are based on information you
provide.


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/a Pregnant Nursing
Height: inches/cm  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: Small Medium Large
 
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
 
Body Weight
Present Weight: lbs/Kg     Desired Weight: lbs/Kg
Desired loss/gain per week: 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 calculations will override any value you may have entered for Desired Weight.
Body Fat Chart for Women and Men
 
Daily Exercise Calorie Expenditure Goals
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 Activity
 
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:

% 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:
Lose Weight Maintain Weight Gain Weight Increase Athletic Performance
 
Peak Body Weight
What is the most you ever weighed?:   lbs/Kg
When did you weigh this amount?:  
 
Medical Conditions
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):
 
Comments and Additional Information
Please enter additional information you feel is important to consider in your personal assessment.




 



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