Full Name*



Male*



Address*



Female*



City*



State/Prov*



Birth Date*



Country*



Zip/Post. code*



Weight*



Phone*



Height*



E-mail*



Weekly Exercise Information



Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 5 or 6-day period.  Please also provide the frequency and duration of these activities.



Activity




Days


Duration (min)



Activity




Days



Duration (min)



Activity




Days



Duration (min)



Activity




Days



Duration (min)



Activity




Days



Duration (min)



Activity




Days



Duration (min)




How would you rate the activity level of your profession, or what you do during the day (non-exercise related).




Sedentary




Moderately Active




Active




Very Active




Goal Weight



Ib.




Lose Weight




Maintain & Improve Eating Habits




Gain Weight/Muscle



Which Best Describes You?




Sedentary Adult




Exercising Adult




Competitive Athlete




Teenage Building Muscle




Adult Building Muscle




Athlete Restricting Calories



Which Best Describes You?




I can eat anything I want and I have a hard time gaining weight.




I can lose or gain weight by adjusting my activity level and eating habits.




I find it difficult to lose weight.  I can gain weight easily and have to watch what I eat.




No.  I do not have any medical conditions




Yes.  I am on medication (provide detail below)




Yes.  I have a medical condition(s).  I have provided information regarding my condition below.



Please describe in what you ate yesterday.  Include portion sizes (e.g., small, medium, large) any drinks or snacks and vitamins or supplements.  Provide as much detail as you like.

If you know your "RMR and BODY FAT percentage"(both Optional), please include them in the Food Diary section.




Finished! Press the Submit button to forward your profile information to one of our weight management consultants. Incorrect field! Press the Reset button.

*INCOMPLETE FORM WILL NOT BE PROCESSED.




Thank You!  A consultant will respond via email within 8 hours or less.



Personal Profile Information



Lifestyle / Professional Activity



What Is Your Goal?


Health & Medical Conditions


One Day Food Diary


DIET PROFILE QUESTIONNAIRE

Have you ever asked yourself, "How many calories, how much protein and really how much fat should I be eating to meet my goals?"  Well it couldn't be any easier than this! Complete all of the information in the form below.  Once complete click the Submit button at the bottom of the page.  We will process your personal profile information and Email you your FREE Dietary profile.  It costs nothing but a few minutes of your time to complete the following form. ONLY COMPLETED FORM WILL BE PROCESSED.



Providing easy, online access to government information on food and human nutrition for consumers.
A service of the National Agricultural Library, USDA.



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