shape and wellness assessment
Eat better to live better
www.beautysane.com My well-being path!
Name and first name : . ....................................................................................................................... Advisor’s name : ................................................................................................................................. Contact details : . ................................................................................................................................
Shape and wellness assessment Date : ……………………………. Name
First name
Address
Postal Code
Mobile phone No.
Phone No.
Email
Profession
Birth date
Age
City Phone call hour
Family status
Number of children
Current weight
W = ………… (kg)
………… (lb)
Current height
H = ………… (m)
………… (in)
Do you have a pathology requiring a particular diet? (thyroid issues, diabetes…)
Yes No Which one ?............................................................................................................................................................ Do you have any allergy ? (cow milk, iodine, gluten…)
Yes No Which one ?............................................................................................................................................................ If you have any of those, kindly contact your doctor who will validate with you the possibility to start a Beautysané programme.
Your alimentary habits : Breakfast … : ... am
Snack … : ... am
Lunch … : … pm
Snack … : ... pm
Dinner … : … pm
Coffee - Tea
Fruits
Crudités
Fruits
Crudités
Kind of bread ? ...............
....................................
Cooked pork meats
....................................
Soup
Butter / margarine
Slices of bread
Meat
Slices of bread
Cooked pork meats
Jam / marmalade
Cakes
Fish
Cakes
Meat
Honey
Yoghurt / «fromage blanc»
Starches
Yoghurt / «fromage blanc»
Fish
Chocolate
(quark)
Vegetables
(quark)
Starches
Milk (vegetal / animal)
Other : .................................
Cheese
Other : .................................
Vegetables
Cereals
Dessert
Cheese
Eggs
Salad
Dessert
Ham
Bread
Salad
Yoghurt / «fromage blanc»
Sandwich
Bread
(quark)
Other : .................................
Other : .................................
Other : ................................. Evening’s habits : Herbal tea Salt consumption: low Meal skipped : YES
Coffee
normal NO
Snacking between meals : YES
Piece of chocolate
Others :
high Vegetables : regularly
NO
rarely
Water only : < 1,5 l
> 1,5 l
Soda :
Particular notes : ............................................................................................................................................................................
Your assessment Body schema : Slim
Normal
Sportive/muscular
Overweight
Obese
Current BMI W ( in kg) / (H in m x H in m) = .............................................. BMI :
18,5
Underweight
25
Normal weight
30
Overweight
35
Medium obesity
40
Severe obesity
Morbid obesity
% of Fat body mass (FBM) . ........................................................................
Body fat levels table (for persons having a normal physical activity - not adapted to sportsmen/women with intensive practice) Age
Female
Underweight
Normal
Overweight Obesity
20 - 39 years old 40 - 59 years old 60 - 79 years old 0 %
Male
10 %
20 %
30 %
40 %
20 - 39 years old 40 - 59 years old 60 - 79 years old Underweight
Normal
Your goals Weight loss
Balance and well-being
Weight gain
Wished weight : …...……….. (kg) / …...……….. (lb) Current clothing size: top ....................... down ....................... Wished clothing size: top ....................... down ....................... How long do you wish to take to reach this result?........................ Comments
Overweight
Obesity
Your follow up Board Measurements of the circumferences of (in cm or in): Date Chest
Under chest
Height
Hips
Thighs
Arms
Weight (kg or lb)
Accumulated weight lost (kg or lb)
How to take the measurements?
6
6 1
1
2
3
3
2. Under chest size Only for women. Take horizontally 3. Waist size Around the narrowest part of the waist 4. Hip size Around the fullest part of the hip
4 4 5
1. Chest size Women: at the breast’s points level, horizontally Men: at the fullest part of the chest
5. Thigh size* Around the fullest part of the thigh 6. Arm size*
5
*always take the same thigh and same arm
3 steps To reach and keep your weight and shape goal !
RAPID LOSS
Beautysané® has created a triphasic programme which can be adapted to your needs and to your life rhythm with your advisor’s help.
GENTLE LOSS STABILIZATION Starter phase
Transition phase
Consolidation phase
Step 1, I rapidly lose weight with the Energy Diet® Starter phase The starter phase is an intensive short-lived phase, which goal is to rapidly lose centimeters and reactivate the fat burning metabolism, by preserving the muscle mass. Period: 3 to 5 days 3 to 5 Energy Diet® meals/day Breakfast + 10.00 am snack (optional) Lunch + 4.00 pm snack (optional) Dinner Beverages: tea, coffee, herbal tea without sugar, in moderation Water: at least 2 L / day.
ure
m e as
a c o n c re a
12
ure
m e as
1
soup
lé
12
-b
In moderation
m
Ene
ure
Ene
m e as
me brû
ure
o m e l e t te
e
ure
ure
Ene
Ene
ure
ure
ure
12 crè
s
o
m e as
rgy Die ®
rgy Die
t
m e as
Pe a
m e as
1
1
Dinner
®
12
D rg y i e
t
m e as
4.00 pm snack (optional)
®
12
va nill a
®
puccin
t
m e as
D rg y ie
Lunch
t
m e as
®
cap
ure
1
D rg y i e
1
10.00 am snack (optional)
t
Ene
Breakfast
m e as
Tea, herbal tea, coffee without sugar
Water at will and at least 2 L /day
Step 2 , I keep on gently losing weight with the Energy Diet® Transition phase The transition phase allows you to reintroduce some foods. You learn again how to eat healthy and balanced with your advisor’s help. Period: depending on how many kilos have to be lost. To be adapted according to the goals defined with your advisor. 2 Energy Diet® meals / day (for instance, for breakfast and dinner) Beverages: tea, coffee, herbal tea without sugar, in moderation Water: at least 2 L/day. Lunch: You reintroduce animals proteins such as eggs (2), fish or meat (from 100 to 150g), together with some vegetables (see table below). For a moment of pleasure, rediscover the fruit flavor (1 per day, the morning at breakfast, during the 10.00 am or 4.00 pm snack, avoiding the very sweet fruits like bananas, fruits in syrup, dried fruits, and always favoring the fruits of the season.
Choose among: Meat, fish, eggs
Vegetables asparagus eggplant Swiss chard broccoli cardoon celery celeriac mushrooms
Brussels sprout cauliflower red cabbage white cabbage cucumber pickles zucchini watercress
endives spinach fennel bean sprouts French beans lamb’s lettuce turnip sorrel
dandelion leek red pepper green pepper radish lettuce salsify tomatoes…
2 eggs 100g lean beef, game, liver, veal... 150g poultry, chicken, rabbit… 150g poached fish, seafood, shellfish…
Step 3, I consolidate my weight loss with the Energy Diet® Consolidation phase. The consolidation phase enables you to stabilize your new weight and preserve your nice silhouette. Period: 1 month per kilo lost 1 Energy Diet® meal / day Beverages: tea, coffee, herbal tea without sugar, in moderation Good habit to keep : drink at least 2 L of water Lunch: In addition to the foods of the second phase, you reintroduce the cereal and legume products (lentil, dry beans, red beans, rice, pasta and wholemeal bread).
Lunch and dinner: It is essential to rebalance the diet on the
long term view. You learn how to create light and diversified menus, that will bring you all essentials nutrients for the good functioning of the body !
Dinner Vegetables : Choose among: Meat, fish, eggs
See the suggested vegetables for lunch 2 eggs 100g lean beef, game, liver, veal... 150g poultry, chicken, rabbit… 150g poached fish, seafood, shellfish…
® al at breakfast, e your Energy Diet me We recommend to tak or dinner ! ch ssible to have it at lun but it is of course po
For a tasty and tonic breakfast, discover the different pleasures with all the sweet
Energy Diet® flavors !
www.beautysane.com My well-being path!
Name and first name : . ....................................................................................................................... Advisor’s name : ................................................................................................................................. Contact details : . ................................................................................................................................
Shape and wellness assessment Date : ……………………………. Name
First name
Address
Postal Code
Mobile phone No.
Phone No.
Profession
Birth date
Age
City Phone call hour
Family status
Number of children
Current weight
W = ………… (kg)
………… (lb)
Current height
H = ………… (m)
………… (in)
Do you have a pathology requiring a particular diet? (thyroid issues, diabetes…)
Yes No Which one ?............................................................................................................................................................ Do you have any allergy ? (cow milk, iodine, gluten…)
Yes No Which one ?............................................................................................................................................................ If you have any of those, kindly contact your doctor who will validate with you the possibility to start a Beautysané programme.
Your alimentary habits : Breakfast … : ... am
Snack … : ... am
Lunch … : … pm
Snack … : ... pm
Dinner … : … pm
Coffee - Tea
Fruits
Crudités
Fruits
Crudités
Kind of bread ? ...............
....................................
Cooked pork meats
....................................
Soup
Butter / margarine
Slices of bread
Meat
Slices of bread
Cooked pork meats
Jam / marmalade
Cakes
Fish
Cakes
Meat
Honey
Yoghurt / «fromage blanc»
Starches
Yoghurt / «fromage blanc»
Fish
Chocolate
(quark)
Vegetables
(quark)
Starches
Milk (vegetal / animal)
Other : .................................
Cheese
Other : .................................
Vegetables
Cereals
Dessert
Cheese
Eggs
Salad
Dessert
Ham
Bread
Salad
Yoghurt / «fromage blanc»
Sandwich
Bread
(quark)
Other : .................................
Other : .................................
Other : ................................. Evening’s habits : Herbal tea Salt consumption: low Meal skipped : YES
Coffee
normal NO
Snacking between meals : YES
Piece of chocolate
Others :
high Vegetables : regularly
NO
rarely
Water only : < 1,5 l
> 1,5 l
Soda :
Particular notes : ............................................................................................................................................................................
Your assessment Body schema : Slim
Normal
Sportive/muscular
Overweight
Obese
Current BMI W ( in kg) / (H in m x H in m) = .............................................. BMI :
18,5
Underweight
25
Normal weight
30
Overweight
35
Medium obesity
40
Severe obesity
Morbid obesity
% of Fat body mass (FBM) . ........................................................................
Body fat levels table (for persons having a normal physical activity - not adapted to sportsmen/women with intensive practice) Age
Female
Underweight
Normal
Overweight Obesity
20 - 39 years old 40 - 59 years old 60 - 79 years old 0 %
Male
10 %
20 %
30 %
40 %
20 - 39 years old 40 - 59 years old 60 - 79 years old Underweight
Normal
Your goals Weight loss
Balance and well-being
Weight gain
Wished weight : …...……….. (kg) / …...……….. (lb) Current clothing size: top ....................... down ....................... Wished clothing size: top ....................... down ....................... How long do you wish to take to reach this result?........................ Comments
Overweight
Obesity
Your follow up Board Measurements of the circumferences of (in cm or in): Date Chest
Under chest
Height
Hips
Thighs
Arms
Weight (kg or lb)
Accumulated weight lost (kg or lb)
How to take the measurements?
6
6 1
1
2
3
3
2. Under chest size Only for women. Take horizontally 3. Waist size Around the narrowest part of the waist 4. Hip size Around the fullest part of the hip
4 4 5
1. Chest size Women: at the breast’s points level, horizontally Men: at the fullest part of the chest
5. Thigh size* Around the fullest part of the thigh 6. Arm size*
5
*always take the same thigh and same arm
3 steps To reach and keep your weight and shape goal !
RAPID LOSS
Beautysané® has created a triphasic programme which can be adapted to your needs and to your life rhythm with your advisor’s help.
GENTLE LOSS STABILIZATION Starter phase
Transition phase
Consolidation phase
Step 1, I rapidly lose weight with the Energy Diet® Starter phase The starter phase is an intensive short-lived phase, which goal is to rapidly lose centimeters and reactivate the fat burning metabolism, by preserving the muscle mass. Period: 3 to 5 days 3 to 5 Energy Diet® meals/day Breakfast + 10.00 am snack (optional) Lunch + 4.00 pm snack (optional) Dinner Beverages: tea, coffee, herbal tea without sugar, in moderation Water: at least 2 L / day.
ure
m e as
a c o n c re a
12
ure
m e as
1
soup
lé
12
-b
In moderation
m
Ene
ure
Ene
m e as
me brû
ure
o m e l e t te
e
ure
ure
Ene
Ene
ure
ure
ure
12 crè
s
o
m e as
rgy Die ®
rgy Die
t
m e as
Pe a
m e as
1
1
Dinner
®
12
D rg y i e
t
m e as
4.00 pm snack (optional)
®
12
va nill a
®
puccin
t
m e as
D rg y ie
Lunch
t
m e as
®
cap
ure
1
D rg y i e
1
10.00 am snack (optional)
t
Ene
Breakfast
m e as
Tea, herbal tea, coffee without sugar
Water at will and at least 2 L /day
Step 2 , I keep on gently losing weight with the Energy Diet® Transition phase The transition phase allows you to reintroduce some foods. You learn again how to eat healthy and balanced with your advisor’s help. Period: depending on how many kilos have to be lost. To be adapted according to the goals defined with your advisor. 2 Energy Diet® meals / day (for instance, for breakfast and dinner) Beverages: tea, coffee, herbal tea without sugar, in moderation Water: at least 2 L/day. Lunch: You reintroduce animals proteins such as eggs (2), fish or meat (from 100 to 150g), together with some vegetables (see table below). For a moment of pleasure, rediscover the fruit flavor (1 per day, the morning at breakfast, during the 10.00 am or 4.00 pm snack, avoiding the very sweet fruits like bananas, fruits in syrup, dried fruits, and always favoring the fruits of the season.
Choose among: Meat, fish, eggs
Vegetables asparagus eggplant Swiss chard broccoli cardoon celery celeriac mushrooms
Brussels sprout cauliflower red cabbage white cabbage cucumber pickles zucchini watercress
endives spinach fennel bean sprouts French beans lamb’s lettuce turnip sorrel
dandelion leek red pepper green pepper radish lettuce salsify tomatoes…
2 eggs 100g lean beef, game, liver, veal... 150g poultry, chicken, rabbit… 150g poached fish, seafood, shellfish…
Step 3, I consolidate my weight loss with the Energy Diet® Consolidation phase. The consolidation phase enables you to stabilize your new weight and preserve your nice silhouette. Period: 1 month per kilo lost 1 Energy Diet® meal / day Beverages: tea, coffee, herbal tea without sugar, in moderation Good habit to keep : drink at least 2 L of water Lunch: In addition to the foods of the second phase, you reintroduce the cereal and legume products (lentil, dry beans, red beans, rice, pasta and wholemeal bread).
Lunch and dinner: It is essential to rebalance the diet on the
long term view. You learn how to create light and diversified menus, that will bring you all essentials nutrients for the good functioning of the body !
Dinner Vegetables : Choose among: Meat, fish, eggs
See the suggested vegetables for lunch 2 eggs 100g lean beef, game, liver, veal... 150g poultry, chicken, rabbit… 150g poached fish, seafood, shellfish…
® al at breakfast, e your Energy Diet me We recommend to tak or dinner ! ch ssible to have it at lun but it is of course po
For a tasty and tonic breakfast, discover the different pleasures with all the sweet
Energy Diet® flavors !
