Profile and Assessment Questionnaire

Required *


New Customers -To get started please fill out our assessment form below so that we can create a personalized meal plan based on your needs.


 

Contact Information


Personal Information

 Male:   Female: 

 N/A   Pregnant:   Nursing: 


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." If there is a very large gap use "X-Large".

 Small   Medium   Large   X-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

 Sedentary   Moderately Active   Very Active 



Optional Information



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

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.
This chart indicates typical body fat contents for various body types, female and male:

Body Type Female Male
AthleteLean 17-22% 10-15%
Normal 22-25% 15-18%
Above Average 25-29% 18-20%
Overfat 29-35% 20-25%
Obese 35+% 25+%

Daily Exercise Calorie Expenditure Goals


 

Insert calories for each day


 


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:

 

(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


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.