542 2nd Avenue Rivers, MB

Ph: (204) 679-7806
Fax: (204) 480-4537
Email: butterfly@mts.net

 Request for Consultation

Please submit the form below and we will contact you to schedule your FREE consultation. Consultations can be conducted in person or by phone and/or email! Our store hours are Tuesday – Saturday 10:00am – 5:00pm but we do schedule clients on evenings and weekends! We look forward to meeting you! All consultations are 100% confidential and will be conducted by a certified nutritionist.

Initial Assessment Questionnaire
This is a sample questionnaire. You change the title; change this copy; add images (like your company logo); change the form’s size, background, and foreground colors; change fonts and sizes; add rules and borders to columns and or rows; resequence and/or rename the fields; add additional form entries; and modify existing entries, etc. to customize the table to suit your needs.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.You will download this file and have NutriBase Clinical SE process it. When this information is processed, NutriBase will log you on as a client… it will “know” 177 things about you. The contact information you provide will be automatically placed into the NutriBase Client Contact Manager.Once you are logged on as a client, we’ll click your name and tell NutriBase to produce a multi-page Initial Assessment Report for you. We can save it as text and include it in the body of an email, we can save it in Rich Text Format which is suitable for use with any word processor, or we can save it as a web page for you to view on our site. We can also produce other reports for you.

Please complete the following form. You can use NutriBase to process the information and produce a custom Initial Assessment Report:

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 Women
Body Weight Charts for Men
 

Resting Heart RateResting 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 DiseaseHiatal Hernia Liver Disease Other
(specify):
 
Comments and Additional Information
Please enter additional information you feel is important to consider in your personal assessment.