Age ______ BMI __________ Body Fat Analysis (Optional) ________
Blood pressure (optional)_________ Cholesterol (Optional) _______
Estimated Calorie Needs: ____________
Estimated protein needs (.8-1.0 gm/kgBW) ______________
Activity level: From ChooseMy Plate.com
Family History: Has anyone in your immediate family ever had
(Check if yes)
Diabetes ______ High blood pressure _______ Stroke_____
Heart Disease ______ Cancer (any kind) _______
Personal Risk Factors:
Do you smoke cigarettes? _____
Rate the stress in your life from 1-10 (ten being the highest) __________
Circle the statement that best describes your alcohol consumption habits.
Never drink Drink moderately Drink more than Drink frequently
(no more than 1-2 /day) moderately on occasion
(more than 3/day occasionally)
Do you ever thaw meats at room temperature?
Do you ever eat high protein foods that have been at room temperature for more than two hours?
Do you reheat food in the microwave until they are very hot?
Do you eat rare hamburger meat?
How often do you eat at fast food restaurants?
Do you eat breakfast?
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