Weight Loss Worksheet

Please complete steps 1-5 below and click submit

Step 1:  Your Bodies' Basics




Age (in years):


Activity Level:

Lowering your calorie intake:


Step 2: What Medical Problems do you have?

Click any conditions for which you have been diagnosed by a medical provider.

Heart Disease High Blood Pressure High Cholesterol
Diabetes Lung Disease Arthritis
Current Pregnancy Gall Bladder Disease Unstable Medical Condition
Unstable Psychiatric Condition Osteoporosis Anorexia


Step 3: Favorite Exercises and Activities

Click a few exercises you're willing to do several times per week

How much exercise will you do?
Days per week:
Minutes per day:
Walking Bicycling Volleyball
Gardening Jogging Badminton (Singles)
House Cleaning Swimming Tennis (Singles)
Golf without a cart Skating (ice, roller) Horseback riding (trot)
Bowling Stair Climbing Table Tennis
Dancing Cross Country Skiing Squash
Aerobics Skipping rope Water Skiing


Step 4: Healthy Foods

Healthier Foods that you're willing to eat

Please uncheck foods you would absolutely not tolerate

Vegetables and Fruits

Milk and Meat



Grapefruit Juice and Fruit Poultry (chicken or turkey) Bagel or english muffin Catsup
Apple Juice and Fruit Fish (fresh or frozen) Rice cakes Jelly or Jams
Orange Juice and Fruit Canned Tuna or Salmon Pancakes Pancake Syrup
Bananas Shellfish (e.g. Shrimp) Cereal (Bran, Cheerios...) Cream Cheese (low fat)
Melons (e.g. Cantelope) Sardines  Spaghetti
Berries (e.g. Strawberry) Veal (not veal cutlets) Potato or Yams
Broccoli or cauliflower Venison (lean cuts) Crackers
Carrots Cold cuts (e.g. turkey) Popcorn or pretzels
Zucchini or squash Yogurt Rice or Couscous
Asparagus Hot cocoa (low calorie) Lentils
Spinach Egg whites or substitute Dried Beans or Peas
Green Beans Low Fat cheese Corn



Step 5: Less Healthy Food

Favorite Foods supporting the notion "Fat tastes good"

Please check a few foods you refuse to live without

Vegetables and Fruits

Milk and Meat



Sweetened fruit juice Chocolate Cookies Mayonnaise
Canned fruit in syrup Ice Cream Brownie Margarine or butter
Commercial fruit filling Beef Cake Salad dressings
Avocados Lamb Doughnut Sour Cream
Olives Pork or ham Muffin Cream Cheese
Nuts Liver Sweet roll or Danish
Fried Vegetables Duck or goose French Fries
Vegetables in sauce Fried fish Tortilla chips or corn chips
Eggs (with yolks) Potato chips
Cheese Granola
Bacon Waffle



Final Step

Please press 'submit' to create a weight reduction program

Press 'reset' to clear your entries and start over


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