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Referred By
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Is your weight normal for your height?
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Yes
No
How many meals do you eat in a day?
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1 Time
2 Times
More than 3 Times
Do you snack, what when & how much?
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What foods you like? (Veg/Non Veg)
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What is your biggest meal of the day?
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Do you over eat? What foods do you over eat?
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Who prepares your meal?
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Do you make sure you eat breakfast? If yes what do you prefer?
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Yes
No
What do you prefer for breakfast
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Do you eat in front of T.V or computer?
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Yes
No
How many times in a week you eat out?
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1 Time
2 Times
More than 3 Times
Do you consume Alcohol? How much per week?
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Yes
No
If Yes, How much per week?
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1 Time
2 Times
More than 3 Times
Do you crave for sweets?
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Yes
No
Do you do any kind of physical activity? Give details?
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Yes
No
If yes.. Give details?
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Are you depressed about your weight gain?
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Yes
No
Are you losing weight for any occasion?
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Yes
No
Any health concern you would like to discuss?
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No
If yes discuss your health issues
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Do you really want to lose weight?
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Yes
No
Will you put in all your effort in making me help you lose weight?
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Yes
No
Can you climb a flight of stairs, walk up a slope or walk briskly without becoming breathless?
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Yes
No
Can you bend down and touch your toes without bending your knees?
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Yes
No
Do you get at least 7 hours sleep each night?
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Yes
No
Do you monitor your weight regularly?
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Yes
No
Are you suffering from any of these symptoms?
*
Muscle cramps
Constant fatigue? Tiredness?
Lethargy? Lack of energy?
Hyper acidity
Bloated stomach
Frequent bouts of depression or irritability
Gradual weight gain
Frequent body ache or headaches
Excessive hunger
Poor appetite
No symptoms
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