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 Motions Bowel Motions Normal Constipation Diarrhoea

Stress levels this week Stress levels this week 0-2 Chilled 3-5 Some stress 6-7 Stressed 8-9 High stress 10 Stressed out

Protein shakes per day Protein shakes per day 0 1 2 3 4

Water per day Water per day 0 litres or gallons 1-2 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 0 1 cup per day 2 cups per day 3+ cups per day

Tea per day Tea per day 0 1 cup per day 2 cups per day 3+ cups per day

Alcohol per week Alcohol per week 0 1 standard glass 2-3 standard glasses 3+ standard glasses

Exercise session per week Exercise session per week 0 1-2 2-4 5+

Sleep hours per night, on average Sleep hours per night, on average 3-4 4-5 6-7 8+

Average ketosis for the week Average ketosis for the week 0 0.5 1.5 4 8+

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