Web Initial Assessment Questionnaire

Use this form to create a profile that we can use to produce a multi-page Basic Initial Assessment Report for you. The results of the form, of course, are not a substitute for seeing a registered dietitian nutritionist for more a more tailored nutrition assessment.  However, the form can offer a lot of basic information, such as calorie goals, a standard protein amount by percentage, and other basic macronutrient calculations. The results of your questionnaire will be returned to you via email within 48 hours.  This is a free service!  If you would like more detailed information or clarification, I recommend signing up for an appointment to discuss your results.  If you are interested in working with us, be sure to sign up for services. Since the url address bar is NOT securely encrypting (https), DO NOT disclose any sensitive information here. Please use the contact form for that. Information is submitted and stored at nutribase.com, the company who supplies the professional nutrition analysis software used in some of my services. Please complete the following form.

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:
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: 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 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 Intensity
PCF Ratio Goal
If you aren't sure what your ratio should be, leave them blank... our Registered Dietitian 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?:	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
Please enter additional information you feel is important to consider in your personal assessment.