Weight Loss Trainer, Exton, Phoenixville, West Chester, Valley Forge, PA

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
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 right

Body Weight Charts for Men right

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

Percentage Body Fat Composition Values
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.

Present % Body Fat Content:

Desired % Body Fat Content:

Body Fat Chart for Women and Men right

Daily Exercise Calorie Expenditure Goals
Exercise Calorie Goal - Monday:

Exercise Calorie Goal - Tuesday:

Exercise Calorie Goal - Wednesday:

Exercise Calorie Goal - Thursday:

Exercise Calorie Goal - Friday:

caloriesExercise Calorie Goal - Saturday:

Exercise Calorie Goal - Sunday:

Exercise Calorie Expenditures Sorted by Activity right

Exercise Calorie Expenditures Sorted by Intensity right

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

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