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)

Sex:

Female

Male

Pregnant/Nursing:

N/A

Pregnant

Nursing

Height:

inches/cm

Age:

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

Present Weight (lbs/Kg):

Desired Weight (lbs/Kg):

Desired loss/gain per week (lbs/Kg):

Resting Heart Rate

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

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.

Daily Exercise Calorie Expenditure Goals

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:

If they don’t, we’ll enter values for you.)

Lose Weight

Maintain Weight

Gain Weight

Increase Athletic Performance

Most you ever weighed?:

lbs/Kg

When did you weigh this?:

Please select as many as apply:

Asthma 

Colitis  

Diabetes 

Gastric Reflux 

Hypertension

Hypoglycemia 

Irritable Bowel Syndrome  

Heart Disease 

Hiatal Hernia  

Liver Disease  

Other (specify): 

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