Questionnaire

Personal Details

Name

Age

Gender

Profession

Veg/ Non-veg

Height

Present Weight

Target Weight

Country Of Residence

Symptoms and medical history

Any Medical history you want to discuss like Gallstones, Gallbladder Removed, Joint problems, thyroid etc,

List chief health day-today symptoms of your health in order of your importance like acidity fatigue, dry eyes, any food allergies?

Present Diet Routine

Breakfast

Snacks

Lunch

Snacks

Dinner

Supplements

Any supplements, herbs you are taking at the moment and whats the Dosage?

Sleep Routine

How many hours do you sleepat night/ From what time to what time you sleep?

Are you able to sleep immediately after lying in bed?

Do you wake up fresh and energetic?

Exercise

Do you exercise daily? How many hours and which form of exercise?

Are you open to join a Gym?

Do you practise any relaxing/Praying/Meditating or Breathing Exercises/How do you destress?

Emotional Health

Do you blame anyone for your health? What do you think, why do you have these health symptoms/Extra Weight?

Are there any emotional experiences that are affecting your health condition?

Is your family/ Spouse supportive of your health and whats his profession?

What do you expect from this consultancy?

Blood Test(Optional): Pls share the recent reports if you have, along with the questionnaire :)

TPO, TGAg

ESR

CRP

VITAMIN D

B12

Iron

Fasting Blood Glucose

Disclaimer

I am a lifestyle consultant, helping my clients lead a healthy life through Weight Control, Exercise and Healthy Eating. Please Note my consultancy does not replace any medical advice you are obtaining or you will need at any future date.

Agree with T&C