PERSONAL DETAILS

Name
Age
Gender
Email id
Height
Weight
Marital Status
Number of kids
Country/ City you reside in
Profession
Food preference
(Vegetarian / Non Vegetarian /
Eggitarian / Vegan)

 Your current health condition:

Health Condition Yes, where applicable

(Blank will be considered as No)
Diabetes
High BP
Low BP
Heart problem
Thyroid
Kidney issues
Liver issues
High lipid levels
PCOD/ PCOS
Skin or hair problems
Migraines
Infertility

 Any other health concerns:

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 How is your digestive health(Any bloating, flatulence, acidity, constipation, loose stools):

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 Family Medical history:

Mother’s side Father’s side

 Any incidences of hospitalization or serious illness?

 Mention list of supplements or medication that you consume:

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 Food allergies if any? _________________________________________________________

For Women

 Females- Menstrual Cycle - Regular/Irregular

 How many days is your flow?
 Are your periods painful?
 Have you reached or are you approaching menopause?
 UTI

 Activity level/ workout routine: _________________________________________________

 Do you exercise regularly or play any sports? What kind of exercise/ sports? How many days

in a week?

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 Sleep duration and sleep quality per night? Specify your sleep and wake up time

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 Stress levels: Low / Medium/ High / Very High

 What are the main cause/ source of stress?

 How is your emotional health?

 Do your express or internalize your emotions?

 Are you an emotional eater?

 How many glasses of water / liters of water do you drink daily?

 Do you smoke? How many and how often?

 Alcohol Intake (Types/Mixers/Frequency)

 Coffee/Tea intake (frequency, with or without milk/sugar)

 Health goals you would want to achieve through this program:

 Most important thing that you will change about your diet to improve your health?

 Please fill up your diet recall (timings are important)

Meals Timings Food consumed

Wakeup

Breakfast

Mid Morning

Lunch

Evening

Dinner

Post dinner

Please share some details about your lifestyle -daily or weekly schedule with approximate
timings (include office hours and/or travelling hours, if any)

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Please feel free to add any more details that you think might help us while making your food
plan. Medical reports’ parameters would also help.
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