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Initial Assessment

Make It Happen!

The tragedy in life is not that it ends so soon, but that we take so long to begin living it."
- Anonymous

Stop wasting your time and money on ineffective "one-size-fits-all" programs, diets and products! What works for you best friend, family member or co-worker may not work for you. It's time you had your own diet and exercise program customized to your unique needs, abilities, goals, lifestyle and interests. Want to see what you are actually capable of accomplishing? Let me show you.

Fill out the form below for a FREE evaluation and consultation. It's easy, it's free and I know you will find the results of my analysis worth the few minutes of your time. After I receive your questionnaire, I will evaluate your answers and contact you to set up a time for us to meet and review the program I think will best meet your needs. I know you will find the results "life-changing".

Required information.

Optional information.




Contact Information





























Unit of Measure




Personal Information


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."




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.






Body Weight





Desired loss/gain per week (lbs/Kg):

Body Weight Charts for Women right
Body Weight Charts for Men right

Please enter your heart rate, measured first thing in the morning before you get out of bed.



Percentage Body Fat Composition Values




Body Fat Chart for Women and Men right

Daily Exercise Calorie Expenditure Goals














Exercise Calorie Expenditures Sorted by Activity right
Exercise Calorie Expenditures Sorted by Intensity right

PCF Ratio Goal







(These three percentages must equal 100%. If they don't, we'll enter values for you.)

Personal Goal





Peak Body Weight






Medical Conditions

Anemia
Asthma
Colitis
Diabetes
Gastric Reflux
Hypertension Hypoglycemia
Irritable Bowel Syndrome
Heart Disease
Hiatal Hernia
Liver Disease
Other (specify):

Please enter additional information you feel is important to consider in your personal assessment.







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