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Please take your time to fill in this Assessment Form.
First Name
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Last Name
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Gender
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Address
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City
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State / Province
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Postal / Zip Code
Email
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Phone
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Number of Family Members
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Occupation with Work Timings
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Mode of Transportation
Private Wheeler
Local Train
Bus
Rickshaw
Walking
Measurements
Age (in years)
Height (in feet and inches)
Weight (in Kg)
Waist Circumference
Neck Circumference
Hip Circumference
Medical History
I have been previously/currently diagnosed with
High Blood Pressure
Heart Disease
High Cholestrol
Diabetes
Stroke
Thyroid
PCOS
Osteoporosis
My father, mother, brother or sister has/had
High Blood Pressure
Heart Disease
High Cholestrol
Diabetes
Stroke
Thyroid
PCOS
Osteoporosis
Medications (if any)
Personal Habits
Do you smoke?
If yes, how many per day?
Do you drink alcohol?
If yes, how much and how often?
Other Tobacco Products
Water Intake (in glasses/litres per day)
Sleeping Hours
What kind of Sleep do you have?
Sound sleep
Disturbed sleep
Light sleep
Keep on awakening in between
Stress Levels
No Stress
Mild Stress
Moderate Stress
High Stress
Extreme Stress
Clinical Symptoms
Do you suffer from any of these symptoms?
Tiredness
Joint Pain
Bloating / Gas Formation
Constipation
Frequent Hunger
Loss of apetite
Dizziness
Missed periods
Increased Hairfall
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 / Strength Training / Flexibility / Stretching exercises
How many minutes a day are you physically active?
Diet Pattern
Food Habits
Vegetarian
Non-vegetarian
Eggetarian
How many times do you eat fast food in a week?
How many litres of oil do you use at home in a month?
How many kilograms of sugar do you use at home in a month?
How many cups of tea/coffee do you dink in a day?
Do you take any Health supplements? If yes then mention name.
Food of your liking
Foods you dislike / intolerance
Explain your daily eating habits with timings
Wake-up time
Morning tea time
Breakfast
Mid-morning
Lunch
Afternoon Tea
Evening Snacks
Dinner
Bedtime
Since when has your case occurred 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
Please select a suitable date for appointment.
Please select a suitable time for appointment.
Hours
Minutes
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PM
Do you have any blood reports of last 6 month? If yes, then please attach all relevant reports.
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