Name:
Today's date:
Age:
Height (in.):
Weight (lb.):
Waist size (in.):
BMI: Use the BMI chart from Chapter 4 or use this equation:
wt (lb.)
Height (in.) x height (in.)
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x 703 =
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BMI ranges:
- < 18.5 = underweight
- 18.5�.9 = normal weight
- 25�.9 = overweight
- > 30 = obese
My BMI indicates that I am: (Please circle)
underweight normal weight overweight obese
My risk factors are: (Please circle)
- high blood pressure (hypertension)
- high LDL cholesterol
("bad" cholesterol)
- low HDL cholesterol
("good" cholesterol)
- high triglycerides
- high blood glucose (sugar)
- family history of premature
heart disease
- physical inactivity
- cigarette smoking
My physical activity level is: (Please circle)
sedentary moderately active active
- Sedentary means a lifestyle that includes only the light physical activity associated
with typical day-to-day life.
- Moderately active means a lifestyle that includes physical activity equivalent to
walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light
physical activity associated with typical day-to-day life.
- Active means a lifestyle that includes physical activity equivalent to walking more
than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity
associated with typical day-to-day life.
A healthy weight range for my height is: (Based on the BMI chart)
Estimated daily calorie needs, my goal:
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