Receive your FREE MULTI-PAGE ASSESSMENT REPORT Please complete the following form:
ADDITIONAL NOTES:
You can put in an X in
place of your phone number if desired.
We email your report so please check that it
is accurate.
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.
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:
