Counselling

Please fill out this questionnaire prior to your Consultation. This information will contribute to the development of a program based on your needs and current lifestyle habits. Please feel free to include any additional information that you feel might be relevant to your current situation

Full Name

Goals for this consultation *

Gender

Male Female Prefer not to say

Age

Marital Status

Married Unmarried

Job Profile

Current Height/Weight

Blood Group

Have you ever had your body composition measured ?

Yes No

Your Sleeping Hours

Do you have any food allergies or intolerances?

Do you take any vitamin, mineral or herbal supplements, medication? Please mention

Your Physical activity level. Check those that may apply

Sedentary lifestyle ( little or No Exercise, desk job) Moderately Active (Walk, Exercise 3-4 days weekly) Very Active (Walk, Exercise daily ) Other

Your family medical history (IF ANY)

Your medical history, (IF ANY)

Your food specifications. Check those that may apply

Vegetarian Non – Vegetarian Vegan ( No Egg, Milk, Meat ) Lacto – Ova Vegetarian ( Egg included ) Option 5 Other

Your Food likes & Dislikes

Do you get routine health checkup done?

Yes No Other:

Do you Smoke

Yes No Other:

Please provide your daily food Routine with your Meal timings * 24hrs Diet recall (What do you eat through out day like breakfast, lunch, dinner along with time) Mention all

Consent *
I declare all information given by me is correct .I am consulting a nutritionist & dietician for my better health and will follow plan as guided by them. They are my food & health advisor not doctors.

Agree Other:

Disclaimer
We do not give any magical foods, pills, crash diet which harm you or use any instruments that melt away excess body fat in a couple of days. Rather we use your weight/height/bmr/bmi along with blood work to calculate and plan diet as per your requirements. No advice or information, obtained by you from us does not create guarantee as body can lose up to certain level or your problems will subside for sure! Moreover it all depends upon other factors as well like activity level, age, medical issues, sleep pattern, belief system, and your follow up. A right combination of diet, lifestyle, motivation and dedication is the only way to sustain long term goals. Make sure you set a mindset after reading this before starting on this journey with us as we can always try for best.

Agree Other:

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Contact

shivani.gulati376@gmail.com
98550 37376

Location

Ojas Hospital H-1 sector 26 panchkula
Timing: Monday to Saturday: 10:00 AM - 4:00 PM Closed on Sundays

SCF 57, Sector 8, Panchkula
By appointments only

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