Quincy Roberts Nutritional Meal Planning
Initial Assessment Questionnaire

This is a questionnaire to gather information about you ,so we can set you up on the Phone App and Online meal plan of your choice. ,

Your username and passwords will be emailed to you. Information on the assessment will include,how many calories and other fitness information that can be important
to you for reaching your particular goals in a healthy and effective way.On the questionaire you will find charts that give information on the ideal weight you should
be for your height,age and frame.We are also able to advise you on meal plans by email .Afer completing the form you will see more information on how to aquire all
these important facts.
When you click the submit button, our script checks your entries and makes sure that all the required fields are filled in. It also checks to make sure the email address
is properly formatted. If something is amiss, a message appears and directs you to the fields that need to be corrected. If everything is okay, this data is copied to a
flat-file (text-based) database on our server.

We will download this file and have Quincy Roberts ,takethis information to be processed,Quincy will log you on as a client. .Quincy will contact you on how to use the App ,plus you will recieve email with video on how to use the app.

Please review the meal plans listed below and choose the Meal Plan best suited to your lifestyle and health goals. Below in on questionnaire in the
COMMENT BLOCK list the name of the plan that you prefer. List of Meal Plans on App

hyoertension Men
* 30 Dat Hypertension Women
* 30 Day New Moms Post
* 30 Day Pre/Post Natal Lactating
* 30 Day Weight Loss Men
* 30 Day Weight Loss Women
* 30 Day Womens Anti ahimg
GENERAL GENERAL Fitness & Performance Glycemic Management Special
* Anti-Aging
* Asian Explosion
* Energy Booster
* Healthy Aging
* Healthy Cholestrol
* Heart Healthy
* Heart Healthy Living
* Low Carb
* Low Carb American
* Low Carb
* Low Carb American
* Low Carb Italian
* Low Carb Lifestyle
* Low Carb Mexican
* Low Carb Cholesterol
* Mature Women

* Mediterrean
* North Beach Diet Phase 1
* North Beach Diet Phase 2
* On the Go
* On The Go R2
* Sustained Energy
* Teen Lifestyle
* Teen Scene
* Weight Loss R2
* Women Healthy Aging

 30 Day Plans

* 30 Day Cholestrol
* 30 Day Heart Healthy Men
* 30 Day Heart Healthy Women
* 30 Day Hypertension Men
* 30 Day Hypertension Women
* 30 Day New Moms Post Pregnency
* 30 Day Pre/Post Natal Lactating
* 30 Day Weight loss Men
* 30 Day weight loss Women
* 30 Day Women Anti aging

* Atheletic Training
* Lean and Tone Physique
* Lean Bodybuilder
* Mass Builder
* Muscle Builder
* Paleo ( Caveman )
* Paleo Lifestyle
* Peformance Training

Bariatric & Medical Supervised

* Ketogenic

True Paleo

* True Paleo Autoimmune
* True Paleo Fodmap

* Hi Low Glycemic R2
* High (am ) to Low (am )
* Glycemic
* Low ( am) to High(pm) Glycemic
* Low Glycemic
* Low Glycemic R2
* Low to High Glycemic R2

Disease Prevention

* Breast Cancer
* Cancer Prevention
* Cancer Prevention R2
* Heart Disease
* Heart Disease Prevention R2
* Osteoporosis Prevention R2
* Osteopososis ( Bone Health)
* Stable Blood Sugar R2
Stable Blood Sugar R2
* Stroke Prevention
* Strokr Prevention R2 

* Gluten Free
* Healthy Soy
* High Fiber
* Intermittent Fasting 16;8
* Intermittent Fasting 7:2
* Intermittent Fasting Alternate Day
* Kosher
* Lactose Intolerant
* Organic Low Carb
* Organic Low Fat
* Vegan
* Vegan Lifestyle
*Vegetarian Lifestyle
* Wheat Free
* Wheat Free Sensitivity 

Detox & Cleanse

*21 Day Detox Fruit Men
*21 Day Detox Fruit Women
* 21 Day Detox Meat For Men
* 21 Day Detox Veggie For Men
* 21 Day Veggie Detox Women
* Detox with Fruit for Men
* Detox with Fruit for Women
* Detox with Meat Men
* Detox with Meat Women
* Detox with Veggie formr Men
* Detox with Veggie for Women  

 

 


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."
Body Frame: 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.

Activity level: 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 WomenBody Weight Charts for Men
 
Resting Heart Rate
Resting Heart Rate:
Please enter your heart rate, measured first thing in the morning before you get out of bed.
 
Percentage Body Fat Composition Values
Present % Body Fat Content:     Desired % Body Fat Content:
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.
Body Fat Chart for Women and Men
 
Daily Exercise Calorie Expenditure Goals
Exercise Calorie Goal - Monday:       calories
Exercise Calorie Goal - Tuesday:       calories
Exercise Calorie Goal - Wednesday:       calories
Exercise Calorie Goal - Thursday:       calories
Exercise Calorie Goal - Friday:       calories    
Exercise Calorie Goal - Saturday:       calories
Exercise Calorie Goal - Sunday:       calories
Exercise Calorie Expenditures Sorted by Activity     Exercise Calorie Expenditures Sorted by Intensity
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
Peak Body Weight
What is the most you ever weighed?:   lbs/Kg
When did you weigh this amount?:  
Medical Conditions
Please select as many as apply:
  Anemia
  Asthma
  Colitis
  Diabetes
  Gastric Reflux
  Hypertension
Hypoglycemia
Irritable Bowel Syndrome
Heart Disease
Hiatal Hernia
Liver Disease
Other (specify):
Comments and Additional Information
Please enter additional information you feel is important to consider in your personal assessment.