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Consultation for Nutrition and Wellness
A short screening to understand the present condition and how diet can influence and bring a change in daily life. Complete Package of Counselling and Diet Plan - Rs.200 INR
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Email id
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Full Name
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Age:
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Date of Birth
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Contact number (Preferred the whatsapp number)
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Address
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City
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State
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Gender
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Male
Female
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Other:
Profession
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What is your suitable time for consultation?
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Current Weight (in kgs)
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Current Height (cms)
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Blood group
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Who cares for you? (If at home with whom do you stay, if at hostel or other place mention)
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Marital Status
Single
Married
Divorcee
Prefer not to say
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Food preferences
Vegetarian
Vegan
Non-vegetarian
Lacto-ovo vegetarian
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Do you have any food allergies, sensitivities or intolerance?
Yes
No
Maybe
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What are your nutrition goals?
Lose/Gain weight
Maintain weight
Improve physical fitness
Have more energy and vitality
Get control of eating habits
Get stronger
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Please list all of your concerns about your health, eating habits, fitness, and / or body
Your answer
Out of all of the above concerns, which ones feel most important / urgent and why?
Your answer
What do you expect from me as your nutritionist?
Your answer
Who does most of the grocery shopping in your household? Check all that apply
Me
Roommates
Parents or guardian
Spouse
Maid/Servant
Who does most of the cooking in your household? Check all that apply
Me
Roommates
Parents/Guardian
Spouse
Maid/Servant
Who decides on most of the menus / meal types in your household? Check all that apply.
Me
Roommates
Parents/Guardian
Spouse
Right now, how much do the people and things around you support health, fitness, and / or behavior change? (Rate from 1 to 10)
Your answer
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
Yes
No
Maybe
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Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
Your answer
Right now, are you taking any medications, either over-the-counter or prescription?
Yes
No
Maybe
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On a scale of 1-10, how would you rank your health right now and why?
Your answer
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
Your answer
On average, how many hours per night do you sleep?
4 hours or less than
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
More than 10 hours
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Do you drink alcohol?
Yes
No
Sometimes
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Do you smoke?
Yes
No
Sometimes
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Do you exercise/yoga/meditation?
Yes
No
Sometimes
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What is general eating pattern?
Your answer
How many meals do you take in a day?
0
1
2
3
4
5
6
7
Do you skip breakfast?
Yes
No
Maybe
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Amount of water consumed each day
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How often do you eat out?
Never
Occasionally
Sometimes
Always
Often
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Any Family Medical History
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