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?


Yes / No

Medication for same



High Blood Pressure


Diabetes Mellitus




Hormonal Disturbance




Irregular Period (For Females)




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




Relation with you





  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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