Analysis of Body, Diet, General Health & Preventive Steps

Date: ________________
Client Name: _______________________
Address: ___________________________
___________________________

Profession:________________
Age:_______________
Tel. No: __________________
___________________________

Email Id: ___________________________

Mobile No: __________________________


PERSONAL DETAILS

Height: Feet___________ Inches:___________

Current Body Weight (Kgs):__________ Desired Body Weight:_________________

Lifestyle: Active___ Sedentary___
No. Of children (if applicable):

PERSONAL INFORMATION (write Y if Yes where applicable or leave blank):

Muscular/Skeletal problems: Back Pain__ Other Muscle Aches/Pain__ Stiff joints__ Headaches__
Digestive problems: Constipation__ Bloating__ Liver/Gall bladder__ Upset Stomach__
Circulation: High Blood pressure__ Fluid retention__ Tired legs__ Varicose veins__ Cellulite__
Kidney problems__ Cold hands and feet__

Gynaecological: Irregular periods__ Menopause__
Nervous system: Migraine__ Tension__ Stress__ Depression__
Immune system: Prone to infections__ Sore throats__ Colds__ Blocked Chest__ Sinuses__
Regular antibiotic/medication taken:_____________


Ability to relax: Good__ Moderate__ Poor__
Sleep patterns: Good__ Poor__ Average No. of hours:______________
Do you see natural daylight in your workplace? Yes__ No__

Do you work at a computer? Yes__ No__ If yes how many hours:_________
Do you eat regular meals? Yes__ No__
Do you eat in a hurry? Yes__ No__
Do you take any food/vitamin supplements? Yes__ No__

How many portions of each of these items does your diet contain per day?
Fresh fruit: Fresh vegetables: Protein: source? ____________

Dairy produce: Sweet things: Added salt: Added sugar:


How many units of these drinks do you consume per day?

Tea: Coffee: Fruit juice: Water: Soft drinks: Others:
Do you suffer from food allergies? Yes__ No__ Bingeing? Yes__ No__
Overeating? Yes__ No__
Do you smoke? No __ Yes __ How many per day? _________
Do you drink alcohol? No__ Yes__ How many units per day? ________
Do you consume any type of tobacco products orally? ______

Do you exercise? None__ Occasional__ Irregular__ Regular__ Types-_____________________

What is your skin type? Dry__ Oil__ Combination__ Sensitive__ Dehydrated__
Does your skin has any rashes, pimples or any prolonged itching on any part of the body? __

What is your Hair Type? Soft & Silky____ Dry_____ Rough____ Dandruff____ Hair fall & Baldness_____
Split Ends______

How do your nails look? Pink____ White_____ Discoloured_____ Easily Breakable_______

How are your Teeth? White_____ Yellowish______ Suffering from Bad Breath_____ Suffering from

Bleeding Gums_______ Are your teeth sensitive to hot or cold beverages_______


Do you suffer/have you suffered from: Dermatitis__ Acne__ Eczema__ Psoriasis__
Allergies__ Hay Fever__ Asthma__ Skin cancer__

Stress level: 110 (10 being the highest)
At work:__________________ At home:_________________


General Questions (Write Yes if applicable or leave blank)

Do you get tired while climbing stairs (min 2-3 floors)? ____

Do you get out of breath after running a short distance? ____

Do you skip your Lunch? ____

Are you meal timing fixed or irregular? ____

Do you feel exhausted/ out of energy easily? ____

Did you undergo any kind of Surgery? ____

If yes, please specify? ___________________________________________

Any Other Health Complaints do you suffer?

______________________________________________________________


Family History
Heart attack / stroke / sudden death Father / Mother / Siblings
Diabetes Father / Mother / Siblings
High blood pressure Father / Mother / Siblings
Obesity Father / Mother / Siblings
High cholesterol / lipid levels Father / Mother / Siblings


Food Log

Write in items of Cups/Katoris & teaspoons / tablespoons. Specify the quantities of chappatis/idlis


Early Morning: Time:___________________

_______________________________________________________________________________


Breakfast: Time:___________________

________________________________________________________________________________


Mid Morning: Time:___________________

________________________________________________________________________________
Lunch: Time:___________________

_________________________________________________________________________________


Evening: Time:____________________

__________________________________________________________________________________


Dinner: Time:_____________________

__________________________________________________________________________________


Bed-time: Time:_____________________

___________________________________________________________________________________



Any Questions or queries? __________________________________________________


Consent: I state and confirm that I have been explained the therapeutic advisory plan with all its
consequences and none of the person shall be liable on account of my joining the program.


Mail this file to datta.abhimanyu@gmail.com