Free Nutrition Assessment

 


FREE Multi-Page Assessment

Free 14 Day Membership

to

Venice Nutrition Online.

You will receive your Free Gifts

by email in normally 48 hours.

You can put in an xx for your phone number.

Required information. Optional information.

 

 

Contact Information

First Name:


Middle Initial :

Last Name:

Address

City:

State:

Postal Code:

Country:

Email Report To:

Phone Number:


Unit of Measure


Select the unit of measure you wish to use for the
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:

 


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.”

Small
Medium
Large


Activity Level

Check the appropriate activity level that closely approximates lifestyle.Examples:Sedentary = working behind a PC.     Moderately Active = waiting tables. Active = construction work.

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

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 %:

Desired Body Fat %:

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


Exercise Calorie Activity


Exercise Activity Intensity

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
PCF Ratio Goal

If you aren’t sure what ratio should be, leave them blank…

our Nutrition Coaches 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

Lose Weight

 

Maintain Weight

 

Gain Weight

 

Increase Athletic Performance


Peak Body Weight

Most you ever weighed?:

lbs/Kg

When did you weigh this?:

 

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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