PRE CONSULTATION DIET FORM
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Online consultation will save your 70% of the time ,50% of the cost & will give you 100% comfort.
It will take only 5 min to fill this form(your first step towards good health)
Please fill this form completely & honestly, this will help us in giving you necessary diet recommendations.
Please provide the blood report where it is asked. You may send the scanned copy/picture of blood report on mail or Whatsapp.
If you find difficulty in filling any question/s please leave it ,we will ask you during online consultation.
Question for Hormonal Imbalance is relevant to females.
Fill the form & send it on- diet@aahaarexpert.com
This is a copyright document , copying it in any form is legal offence. All rights are reserved with Aahaar Expert.
Sec A. (Personal Details)
Date ……………….
I want diet/nutrition consultation for
……………………/…………………………………/…………………………………
(you may put multiple health problems/diseases , e.g. Weight loss, Diabetes, Cardiac etc.)
My fitness goal/s is/are ………………………………………/……………………………………/……………………………………….
(e.g. to loose 10 kg, to control diabetes, lower cholesterol level)
(years / months.)
1. Full Name ………………………………….
2.Gender ………………………………
3. Age ……………………….
4. Email …………………………………………..
5. Mob No. ……………………………………
6. I am on :
7. Height ………(ft)……..(inch)
8.Weight……….. (Kg)
9.Waist circumference …………(inch)
10.Hip circumference ………….(inch)
11. Are you following any diet restriction? Y/N ………………
If yes, pl provide information on Do’s & Don’ts of your diet.
Do’s ………………………………………………………………………………………………………..
Don’ts ………………………………………………………………………………………………………….
Sec. B ( Present Diet Pattern)
i.
ii.
iii.
iv.
v.
vi.
vii.
Vegetarian ( ) Non-Vegetarian ( )
Eggetarian ( )
How many glasses of water do you drink every day? ………………………………
How many cups of tea/coffee do you take every day? ………………………………..
Are you fond of eating sweet items? Y ( ) N ( )
How many times do you take fruits in a week? ……………………………
No. of times you dine out/visit to a restaurant in a month? ……………………………
Are you allergic to any food/s and or fruit/s? Pl mention the name of food/s and or fruit/s:
.……………………………………………………………………………………………………………………………..
Face Book ( ) Twitter (
)
viii.
ix.
x.
xi.
Are you in habit of taking your meals at irregular timings? Y ( ) N ( )
Do you often miss your main meals? Y ( )
N( )
I don’t like following food/fruit?(you may mention multiple names)
………………………………………………………………………………………………………….
Any other point you would like to mention about your present diet pattern/habits.
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
Questions for Pregnant Woman
For How many times have you conceived in the past?
None( ) 1( )
2( )
3( )
4( )
<4
……………..
Have you experienced any complications in the past? Y/ N ………….
If yes,please tell in brief what were the
complications…………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………………
………………………. ……………………………………………………………………………………………………………..
Mention the present week of pregnancy……………………week
Present Medication for Pregnancy
Name of Medicine…………………………..
Timing…………………………………..
Name of Medicine…………………………..
Timing…………………………………..
Name of Medicine…………………………..
Timing…………………………………..
Do you have any illness or disease? Y / N ……………
If yes, mention the name of disease- Hypertension( ) Thyroid( ) Diabetes ( )
Depression( ) Epilepsy( ) Other……………………..
Last Blood Pressure report ……………………………………
Please share your latest/last blood report/s.
(You may send the scanned copy on diet@aahaarexpert.com or whats app on 900 901 3363)
Are you facing any other Pregnancy related complications ,like:
Nausea( ) Vomiting( ) Vertigo( ) Anemia( ) Swelling( ) Diabetes( ) Other………………………….
Present Lifestyle
(Please mention “NA” where ever it is Not Applicable for you)
Time
Food Items
Any
Comment
Wake up
N.A.
Early Meal
Break Fast
Mid Meal
Lunch
Evening Snacks
Evening Tea
Dinner
Bed Time
N.A.
Any other point you would like to mention from your side about your present life style:1 .………………………………………2 .……………………………………3 ………………………………..
Present Physical Activity
Morning
Evening(Radio Button)
Physical Activity
Walk
Any Meditation technique
Yoga
End of Document .
Time (am/pm)
Duration in mins