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DIET PLAN CONSULTATION QUESTIONNAIRE
Please fill in all questions below so that an accurate analysis can be done and a best suited diet plan can be created.
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Full Name
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Contact Number
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Email Address
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Age
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Gender
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Marital Status
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Occupation
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Do you have children? (If yes mention their age)
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Your Height (Ft)
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Your Weight (Kg)
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Medical History (Write brief history)
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List all the Medication, Vitamin, Minerals or any Dietary Supplement you are using:
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List down your allergies (If any)
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Do you smoke?
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Are you currently on a diet or taking medications to loss weight or to maintain your current weight? (If yes, please describe below)
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Do you skip meals?
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How many days per week do you eat, Breakfast? Lunch? and Dinner>
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Do you snack? (If yes when and what)
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Do you buy or pack your lunches? (Please mention number of days per week)
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Do you eat out? (if yes, how many days per week?)
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What type of restaurents do you usually chosse?
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Who usually prepares the food at home?
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What does the grocery shopping?
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How many pieces of fruit do you eat eacch day and how many glasses of fruit juice daily?
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On average, how many servings of vegetables do you eat each day?
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On average, how many times a week do you eat a high-fiber breakfast cereal?
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How many times a week do you eat red meat (beef, muttton)?
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How many times a week do you eat chicken?
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How many times a week do you eat fish?
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What is the portion size of meat/chicken/fish do you eat?
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How many hours of television do you watch each day?
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Do you eat snacks while watching television?
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How many times a week do you eat desserts or sweets?
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How many glasses of water do you drink each day?
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How many glasses of milk do you drink each day?
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Which type of milk do you drink? (Whole milk or Low-fat mil or Skim milk)
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How often do you usually consume dairy products, and which type?
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How many times a week do you drink sodt drinks?
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How many cups of tea/coffee do you take each day?
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How many times a week do you eat rice and what is the usual portion size?
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How many tablespoons of butter/margarine/ghee do you consume each day?
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How much sugar and milk do you add in your tea?
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Do yoy consider yourself?
Underweight
Overweight
Just right
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Sleep time you normally go to bed? Wake up time?
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What did you eat and drink yesterday? Please include portion size and brands if it is possible, i.e; 1 cup of orange juice, 6 ounces, Yogurt, etc. (Please mention breakfast, lunch and dinner and in between snaks along with timings.)
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Any exercuse yo do? Time you spend doing that and number of day you do per week?
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Any other information you would like to share with the Nutrionist please shae so that Diet Plan can be drafted accordingly.
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You got to know about us from
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