BIA Report		Date: ___/___/01
Your bioelectrical impedance analysis (BIA) report and evaluation is below.

Name: __________________________________  Age: ________  Sex:  M   F (circle one) 

Height: ____ cm	 Current Weight: _______ kg    	Resistance: ___ ___ ___  Reactance: ___ ___
Body Mass Index: ________	Goal: 20-25 (less than 18 or more than 27 is associated with health risks for

CPT: 93720    89399 
99199
ICD9-CMs: ________________

some people; >27 is associated with  increased risk of health problems such as 

BCM

heart disease, high blood pressure, and diabetes)

= low

= high

Your BIA will tell you how well you are hydrated, how much muscle and organ tissue you have (called BCM); how much bone, collagen, and fluid outside your BCM you have (called ECM); and an estimation of your fat.  

ECM

Fluids (circle one):	 	Dehydrated		Normally Hydrated		Edema

Knee Ht: _____ cm
Wrist circ: _______
MAC: _______
Waist /Abd: _______
Chest: _______
Breast: _______
Neck: _______
Back: _______
Ridge: ____x____
Knob: ____x____
TSF: _______ mm
BSF: _______
SSC: _______
SIC: _______
ABD: _______
Side: R____L____
Back: _______
Visc R2:Tot R2: ____ 
Thigh _____
Calf _____

Goal weight: 	_____ kg 	Current:		Previous:	
Body Cell Mass (BCM):	_____ kg	_____	Goal: > ____ kg	
Extracelluar Mass (ECM):	_____ kg	_____	Goal: ~ _____-_____ kg
Fat:				_____ kg	_____	Goal: ~ _____-_____ kg
BCM:ECM		_____			Goal:  males: >1.0; females >0.9
Phase angle:		_____			Goal:  males >6.0; females >5.0
To accomplish your goals you may consider discussing the following with your doctor:

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Your dietary needs to maintain your current weight and function:
		_____   liters of fluid each day (coffee and alcohol don’t count!)
	____________  calories each day
	____________  grams of protein each day

Food Group	Serving Size	Comments	
Grains
____ servings	1 slice bread, 1/2 bagel or English muffin
1 small tortilla, 1/2 hamburger bun
1/2 cup cooked rice, pasta, cereal, or potatoes
4-6 crackers	good source of carbohydrate,
calories, B vitamins
whole grains are a source of iron, magnesium, selenium, zinc	
Fruit
____ servings	1/2 cup cooked or canned fruits
1/2 cup fruit juice
1 cup raw fruits*	good source of carbohydrates, vitamins and minerals, especially antioxidants
* follow food safety guidelines	
Vegetables
____ servings	1/2 cup of cooked vegetables
1/2 cup of vegetable juice
1 cup raw vegetables*	good source of vitamins and minerals, especially antioxidants
* follow food safety guidelines	
Dairy
____ servings	8 ounces (1 cup) milk or yogurt
1½ ounces cheese
1½ cup frozen yogurt/ice cream	good source of protein, carbohydrates,        B vitamins, and minerals
use pasteurized products	
Protein Foods
____ servings	3 ounces cooked meat, chicken, or fish
2 cooked eggs 
½ cup nuts or tofu
1 cup cooked dried beans, lentils, peas	best sources of protein
good sources of B vitamins and minerals
3 ounces of meat is about the size 
of a deck of cards