Custom Macronutrient Profile Custom Macronutrient Profile Step 1 of 6 16% Date* MM slash DD slash YYYY Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country BIrthday* MM slash DD slash YYYY Age (in years)* Surgery Type* Lapband Gastric Bypass (RNY) Gastric Sleeve (VSG) Duodenal Switch (DS) Lapband to Gastric Bypass (RNY) Lapband to Sleeve (VSG) Sleeve (VSG) to Gastric Bypass (RNY) Sleeve (VSG) to Duodenal Switch (DS) None Surgery Date* MM slash DD slash YYYY High Weight* Surgery Weight* Does your surgeon know you are participating in this program?* Yes No Medication List* Medical Conditions/Past Injuries/Surgery's* MeasurementsCurrent Weight* Goal Weight* Height (in inches)* Waist (at smallest* Hip Measurement (at widest point)* Neck Measurement (in inches)* NutritionCurrent Calories* How consistent have you been?* Consistent Inconsistent Are you* Losing Gaining Maintaining Macronutrient BreakdownIf you do not have three days of macronutrients, place a 0 in the fields. Day 1Protein (in grams)* Fats (in grams)* Carbohydrates (in grams)* Day 2Protein (in grams)* Fats (in grams)* Carbohydrates (in grams)* Day 3Protein (in grams)* Fats (in grams)* Carbohydrates (in grams)* Daily Activity FactorWeekly Purposeful Exercise* Very Light = (almost no purposeful exercise) Light = (1-3 hours of gentle to moderate exercise) Moderate = (3-4 hours of moderate exercise) Intense = (4-6 hours of moderate to strenuous exercise) Very Intense = (7+ hours of strenuous exercise) Daily Activity Level EXCLUDING Purposeful Exercise* Very Light = (sitting most of day ex. desk job) Light = (a mix of sitting, standing and light activity ex. teacher) Moderate = (continuous gentle to moderate activity ex. waitress/waiter) Heavy = (strenuous activity throughout the day ex. construction worker) How many times a week do you do cardio?* How many times a week do you do resistance training?* Do you work out at home or gym?* Home Gym GoalsDesired rate of weight change per week?* Any personal preferences regarding hight protein/fats/carbohydrates?* Δ
