What is a Web-Based Questionnaire? (Pro SE and Higher)
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The following is a listing of the information that is stored for you when a prospective client submits your we-base client Questionnaire:
1 Date (Date of the submission)
2 Time (Time of the submission)
3 name=fname (First Name)
4 name=mi (Middle Initial)
5 name=Name (First Name)
6 name=Email (Email Address)
7 name=phone (Telephone)
8 name=address1 (Address Line One)
9 name=address2 (Address Line Two)
10 name=city (City)
11 name=state (State)
12 name=postalcode (Postal Code)
13 name=country (Country)
14 name=measure (Measure)
value=“e” (English - inches, lbs.)
value=“m” (Metric - (cm, K(g)
15 name=sex
value=“f” (Female)
value=“m” (Male)
16 name=“p/n” (pregnant/nursin(g)
value=“na” (Not Applicable - checked)
value=“pregnant” (Pregnant)
value=“nursing” (Nursin(g)
17 name=“height”
18 name=“age”
19 name=“bodyframe”
value=“sm” (Small)
value=“md” (Medium)
value=“lg” (Large)
20 name=“activity” (Activity Level)
value=“sed” (Sedentary)
value=“mod” (Moderately Active)
value=“va” (Very Active)
21 name=“presweight” (Present Weight)
22 name=“desweight” (Desired Weight)
23 name=“lgw” (Desired loss or gain/week)
value=“.1” (0.1 lbs.)
value=“.2” (0.2 lbs.)
value=“.3” (0.3 lbs.)
value=“.4” (0.4 lbs.)
value=“.5” (0.5 lbs.)
value=“.6” (0.6 lbs.)
value=“.7” (0.7 lbs.)
value=“.8” (0.8 lbs.)
value=“.9” (0.9 lbs.)
value=“1” (1.0 lbs.)
value=“1.1” (1.1 lbs.)
value=“1.2” (1.2 lbs.)
value=“1.3” (1.3 lbs.)
value=“1.4” (1.4 lbs.)
value=“1.5” (1.5 lbs.)
value=“1.6” (1.6 lbs.)
value=“1.7” (1.7 lbs.)
value=“1.8” (1.8 lbs.)
value=“1.9” (1.9 lbs.)
value=“2.0” (2.0 lbs.)
value=“2.5” (2.5 lbs.)
value=“3” (3.0 lbs.)
24 name=“pfat” (Present body fat content)
25 name=“dfat” (Desired body fat content)
26 name=“monex” (Monday's exercise calories)
27 name=“tueex” (Tuesday's exercise calories)
28 name=“wedex” (Wednesday's exercise calories)
29 name=“thuex” (Thursday's exercise calories)
30 name=“friex” (Friday's exercise calories)
31 name=“satex” (Saturday's exercise calories)
32 name=“sunex” (Sunday's exercise calories)
33 name=“%p” (Percent Protein Goal)
34 name=“%c” (Percent Carbohydrate Goal)
35 name=“%f” (Percent Fat Goal)
36 name=“pg” (Personal Goal)
value=“lw” (Lose Weight)
value=“mw” (Maintain Weight)
value=“gw” (Gain Weight)
value=“iap” (Increase Athletic Performance)
37 name=“pw” (Peak weight)
38 name=“pwhen” (When was this peak weight?)
value=“now” (This is my present weight.)
value=“3mos” (Within the past 3 months.)
value=“6mos” (Within the past 6 months.)
value=“12mos” (Within the past 12 months.)
value=“2yrs” (Within the past 2 years.)
value=“5yrs” (Within the past 5 years.)
value=“5+yr” (More than 5 years ago.)
39 name=“medical” (Medical conditions)
value=“anemia” (Anemia)
value=“asthma” (Asthma)
value=“colitis” (Colitis)
value=“diabetes” (Diabetes)
value=gastricreflux” (Gastric Reflux)
value=“hypertension” (Hypertension)
value=“hypoglycemia” (Hypoglycemia)
value=“ibs” (Irritable Bowel Syndrome)
value=“heart” (Heart Disease)
value=“hernia” (Hiatal Hernia)
value=“liver” (Liver Disease)
value=“other” (Other medical condition)
40 name=“othername” (“Other” medical condition)
41 name=“notes” (Notes and comments)

You may add as many non-mandatory fields as you wish to your form. This listing is for the ones provided with your initial assessment questionnaire... you may add other questions as desired.

Web forms require NutriBase Professional and higher in conjunction with special forms-processing software that we provide and install. Email us at support@nutribase.com.

This topic updated 07/16/2015

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