| Contact Information |
First Name:
MI:
Last: 
Address Line 1:
Address Line 2:
City:
State:
Postal Code:
Country:
Email:
Phone: |
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| Unit of Measure |
Select the unit of measure you wish to use for height and weight entries:
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English (inches, lbs)
Metric (cm, Kg) |
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| Personal Information |
| Sex:
Female
Male |
Pregnant/Nursing:
n/a
Pregnant
Nursing
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| Height:
inches/cm
| Age:
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| 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
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Activity Level
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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
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| Body Weight |
| Present
Weight:
lbs/Kg Desired Weight:
lbs/Kg
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| Desired loss/gain per week:
lbs/Kg |
Body Weight Charts for Women| Body Weight Charts for Men |
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Personal Goal
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This selection is optional. Please select the option that most closely describes your goal:
Lose Weight
Maintain Weight
Gain Weight
Increase Athletic Performance |
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| Peak Body Weight
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| What is
the most you ever weighed?:
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lbs/Kg
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| When did you weigh
this amount?: |
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| | Medical Conditions |
| Please select as many as apply: |
Anemia
Asthma
Colitis
Diabetes
Gastric Reflux
Hypertension
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Hypoglycemia
Irritable Bowel Syndrome
Heart Disease
Hiatal Hernia
Liver Disease
Other
(specify):
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| | Comments and Additional Information |
Please enter additional information you feel is important to consider in your personal assessment.
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