Initial Assessment Questionnaire
This is a questionnaire to assess your current state of health and where you want to go with your health. Please complete as much of this form as accurately as possible so that I can send you as complete a report as possible. The more information your provide, the more accurate the information I can provide.

Thank you for the opportunity to help you and I will be in touch soon to provide you with the results of this assessment.

Yours in health, Brandy.


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: lbs/Kg
Body Weight Charts for WomenBody 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 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.