Dr. Michael Holt - Hypnotherapist, Nutritionalist, Instructor Medical Hypnotherapy - Hypnosis - Nutrition - NLP - Fitness - Herbs - Natural Healthcare, Training and Certification

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NOTE: You can put in an X in place of your phone number if desired.
 


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."


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.

  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 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
 Exercise Calorie Activity                                       Exercise Activity Intensity
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    

 

PCF Ratio Goal

If you aren't sure what your 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:


(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.