Name
*
First Name
Last Name
Gender
*
Male
Female
Others
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Occupation with work timings
Mode of transportation
Private wheeler
Local Train
Bus
Rickshaw
Walking
Other
Back
Next
Number of family members
*
Age
*
Measurements
Your Body Measurements
Values
Normal Values
Remarks
Height (cms)
Weight (kg)
Fat (%)
Visceral Fat (g)
Muscle (%)
Body Age (years)
BMR (kcal)
BMI
Waist Circumference (inch)
Back
Next
Medical History
I have been previously/currently diagnosed with
High Blood Pressure
Heart Disease
High Cholesterol
Diabetes
Stroke
Thyroid
PCOS
Osteoporosis
Other
My father, mother, brother or sister has/had:
High Blood Pressure
Heart Disease
High Cholesterol
Diabetes
Stroke
Thyroid
PCOS
Osteoporosis
Other
Medications (if any)
Back
Next
Personal Habits
Do you smoke?
*
Please Select
Yes
No
If yes, how many a day?
Do you drink alcohol?
*
Please Select
Yes
No
It yes, how often and how much?
Other Tobacco Products:
Yes/No. If yes, please specify
Water Intake
*
How many glasses/litres per day?
Sleeping Hours
*
How many hours do you sleep?
What kind of sleep do you have?
Sound sleep
Disturbed sleep
Light sleep
Keep on awakening in between
Stress levels
*
1
2
3
4
5
6
7
8
9
10
No stress
Extremely stressed
1 is No stress, 10 is Extremely stressed
Back
Next
Clinical Symptoms
Do you suffer from any of these symptoms?
Tiredness
Joint Pain
Bloating/ Gas formation
Constipation
Frequent Hunger
Loss of appetite
Dizziness
Missed periods
Back
Next
Personal Fitness
Are you involved in any of these activities
Walking/ Brisk walking
Jogging/ Running/ Playing any sport
Swimming/ Cycling/ Dancing
Yoga/ Meditation/ Breathing exercises
Weight Training/ Strenth training/ Flexibility/ Stretching exercises
For how many minutes in a day/week are you physically active?
Back
Next
Diet Pattern
Food Habits
Vegetarian
Non-vegetarian
Eggetarian
How many meals do you eat in a day?
*
Please Select
1
2
3
4
5
6
7
8
9
10
eg. breakfast, lunch, dinner, snacks, bedtime, mid-morning
How many times do you eat fast foods in a week
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
eg. pizza, burger, cold drinks, fried foods, packaged foods, wafers, ice-creams
How many litres of oil do you use at home in a month?
Please Select
0
1
2
3
4
5
6
7
8
9
10
How many kilograms of sugar do you use at home in a month?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Do you take any health supplement?
Yes/ No If yes, write the name
Food Likes
Any Food Dislike/ Intolerance
Back
Next
What did you eat yesterday?
Wake-up time
Morning Tea time
Breakfast
Mid-morning
Lunch
Afternoon Tea
Evening Snacks
Dinner
Bedtime
Back
Next
Since when has your case occured and why do you think?
What is your long term health goal and why? Any event looking forward?
Determination level to achieve your goal against all odds
1
2
3
4
5
6
7
8
9
10
May Be
Have to
1 is May Be, 10 is Have to
Submit
Should be Empty: