Weigh-in Form

How to fill out this form:

Use a dressmaker tape measure in centimetres or inches and measure the positions marked in red.

2. The tape measure should go around the complete circumference of each area, as shown.

3. *Measure the buttocks at the point where the bottom sticks out the furthest from the body.

Name

Weight

Neck

Arm

Chest

Waist

Hip

Buttocks

Thigh

Average carbs per day?

Blood pressure (optional)

Bowel MotionsBowel MotionsNormalConstipationDiarrhoea

Stress levels this weekStress levels this week0-2 Chilled3-5 Some stress6-7 Stressed 8-9 High stress 10 Stressed out

Protein shakes per day Protein shakes per day 01234

Water per day Water per day 0 litres or gallons1-2 litre (1/4-1/2 gallon)2-3 litres (1/2-3/4 gallon) 3 litres (3/4 gallons)

Coffee per day Coffee per day 01 cup per day2 cups per day 3 cups per day

Tea per day Tea per day 01 cup per day2 cups per day 3 cups per day

Alcohol per week Alcohol per week 01 standard glass 2-3 standard glasses3 standard glasses

Exercise session per week Exercise session per week 01-22-45

Sleep hours per night, on averageSleep hours per night, on average3-44-56-78

Average ketosis for the weekAverage ketosis for the week00.51.548

Have you taken your supplements this week?Have you taken your supplements this week?Yes No

Have you had any snacks or foods that are NOT on the diet this week? Have you had any snacks or foods that are NOT on the diet this week? Yes No

General comments

Groves Naturopathics

Appointment Policy