Daisey Physical Therapy and The Center for Human Performance

NUTRITIONAL ANALYSIS TOOL
At The Center for Human Performance

Developed by a licensed dietitian.

First, we need to get some information from you in
order to assess your nutritional needs...

First Name:

Age:

Gender:

My Goal is to:

Height:

Feet Inches

Weight:

Pounds

Activity Level:

We need to get an idea of what kinds of activities you engage in when you are awake.

Enter the number of minutes spent each day (or today) engaged in the following activity levels:

Very Light	Light	Moderate	Heavy	Very Heavy
Examples: Reading Driving Eating	Examples: Walking Sweeping Playing Piano Bicycling (easy)	Examples: Fast walking Dancing Light Jogging Skating	Examples: Swimming Running Bicycle (fast pace) Basketball	Examples: Boxing Rowing Heavy weightlifting Mountain climbing

On the following page, you will be asked to enter your food intake for an entire day. There are over 1000 food items to choose from, arranged into 10 categories in the drop-down menus.

If a particular food item is not listed, try to find the item that most closely resembles it. If you dine at a restaurant, they can provide the information necessary to enter portion size.

(This may take
15-20 seconds
to load)