Your Name Your Weight (lbs or add k for kg) EXERCISE HABITS: Your Weekly Run/Walk Miles (add k for Km) Your Weekly Bicycle Miles (add k for Km) Your Weekly Swimming Miles (add k for Km) Your Weekly Hours of Aerobics or Stepper OTHER NORMAL DAILY ACTIVITY LEVEL: (on a scale of 0 to 4) Sedentary Desk Job (0)(4) Manual Labor Have You Consistently Lowered Caloric Intake to Control Your Weight? No Yes