NUTRIHEALTH SYSTEMS PVT.LTD.
Date
:
Name
:
Age
:
Address
:
Email
Occupation :
History of Weight Gain
:
Blood group:
BMI (to be filled by nutritionist) :
Clinical Examination
Anaemic
Pulse
BP
Chest
Oedema
Nature
Ref. By
Date of Birth
Telephone
:
:
:
:
:
:
Distribution of Fat (areas)
Family History
Diabetes
CAD
COPD
Arthritis
Obesity
:
:
:
:
:
Menstrual History
Medical History
Present History
Past History
Constipation
Acidity/gas
Cervical/ spondylitis
Sinus/migrane
Having any medications?
Measurements
Height______
Chest ______
Hips ______
Weight ______
Waist ______
Thighs ______
History of Weight Loss Efforts
- Methods or weights loss program used before
Arms _____
Abdomen _____
Calf ______
:
:
:
-
How much they lost
Physical activity
VEG. / NON-VEG
ROUTINE DIET:
(with time)
B/f :
mid –morning :
lunch:
evening:
dinner:
after dinner :
FOOD FONDNESS:
FOOD DISLIKE:
ALLERGY:
SWEET TOOTH:
LIFE STYLE:
HUNGER TIME
ENERGY LEVEL:
MEALS OUT IN A WEEK:
DIGESTION:
ALCOHOL:
SLEEP CONDITION:
SMOKING/PAN MASALA:
CONSTITUTION FORM
1
Characteri Vata (air)
stics
Skin
dry
2
hair
3
4
thirst
activity
5
weight
6
7
8
Body
frame
appetite
Voice
9
Ra
nk
Pitta (fire)
Ra
nk
Kapha (water)
Oily, prone to acne,
sun burn easily
Fine, straight,
premature gray, oily
excessive
Moderate ,focused
average stamina
Cool, smooth,
moist
Thick, dark,
smooth
low
Lethargic, slow
stamina is good
Put on and loose
easily
medium
Gain easily and
loose slowly
large
Variable, low
Fast, rapid, quick
Very strong
Commanding, sharp
speech
Erratic ,fast ,husky
10
Digestion
evacuation
Often constipated
11
sleep
12
13
temperame
nt
decision
Light, suffer from
insomnia
Nervous, fearful
Decisive ,easily
audible
Strong Digestion
,bowels more than
once
Light, enjoy good
night sleep
Irritable, impatient
moderate
Soft, sweet, not
talkative
Slow and
deliberate
Sluggish Digestion
bowels regular
usually once
Heavy sound, for
long hours
Easy going
difficulty in making
decisions
Decisive, Logical,
forceful
14
memory
Sharp and clear
15
moods
16
weather
17
circulation
Grasp quickly
forget quickly
Change easily
quickly, often take
on project that
don’t complete
Cold, dry weather
bothers prefer
warm
Cold hands and feet
18
Sweat
Minimal
19
20
Pulse
Taste
preferences
Irregular
Prefer sweet, sour
salty foods
Excessive with
pungent odour
Regular/bounding
Prefer sweet, bitter,
astringent Raw
slightly cooked food
Dry, brittle, slightly
wavy
Variable, erratic
active
restless, energy
comes in burst,
Loose easily, hard
to gain
small
Well organized,
perfectionist, enjoy
challenges and
achieving goals
Heat sun bothers
,perspire easily
Prefer cold
Hot hands and feet
Thoughts &action
are well planned &
generally don’t
change
Slow to learn but
retain
Relaxed, regular
lifestyle, complete
project that start
Cold damp
weather bothers
Prefer warm
normal
Heavy without
odour
Regular Smooth
Prefer pungent,
bitter food without
too much of oil
Ran
k