Name : Age :
Height : Nationality :
Address :
Phone No. : E-mail ID :
Current Weight
(Empty Stomach)
Veg or
Non Veg.


   Q-1  Are you having any of these?
 

Disorder

Yes / No

Medication for same

Hypothyroidism

 

High Blood Pressure

 

Diabetes Mellitus

 

Hypercholesterolemia

 

Hormonal Disturbance

 

Depression

 

Irregular Period (For Females)

 

Asthma

 

High Uric Acid (Hyperuracemia)

 

Arthritis / Joint Pains

 

Any Other

 

 
Q-2 Did you had any one of the above listed disorders ever in life time for a short while?  
     If Yes which one -
     

  Q-3 Any Surgery ever?       
 
              
 

  Q-4 If you are a married female (otherwise ignore)
  a) How many deliveries that you had?
  b) Have you lactated all of them; for how long?
  c) Any Abortions (MTP's)

Q-5  Do you have history (Mother / Father / Maternal or Paternal Pools) towards any
          Disorder
like

 

 

Disorder

Relation with you

 

Diabetes

 

  Hypothyroidism
  Hypertension

  Q-6 Do you have any allergy with any Foodstuff?  

       


  Q-7 If you weight Loss or weight Gain patient, have you tried anything before  
  
            


  
Q-8 Do you have any activity right now like :   
 

Q-9 What is your daily diet pattern of what you eat & how much?

 

  a)  Bed Tea   b)  Breakfast  
  c)  Lunch   d)  Evening  
  e)  Dinner   f)  After Dinner  

 

Q-10 How frequently do you eat out?      

  Q-11 Do you smoke?      

 

Q-12 Do you consume Alcohol, If Yes how frequently / How much?

 


           


   Any Suggestions / Query

  

 

 

 

   

 

 

 

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