Intake Baseline

Name: *

First

Last

Date of Birth: *

Gender: *

Male Female

Marital Status: *

Single Married

State or Province: *

Recent Portrait-Style Photo: *

Max file size: 20MB

Waist Circumference: *

Walk/Jog Distance: *

Exercise pattern duing the past 3 months: *

Less than 30 minutes per week 30-90 minutes per week 90-150 minutes per week More than 150 minutes per week

Average # of Fast-Food Meals per Week: *

Average # of Restaurant Meals per Week: *

Beverages consumed during the previous Week (Mark all that apply): *

General Health Status: *

Poor Fair Good Excellent

Regularly use Dietary Supplements? *

Yes No

# of Regular OTC Medications: *

# of Active Rx Medications: *

*If "Other" above, identify below: *

Overnight Hospitalization or Surgery during the previous 12 months? *

Yes No

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