Satvic Nutritionist - Love • Care • Attention.

Nutritional Questionnaire
Many factors affect a person’s health and well-being, such as lifestyle, family medical history, emotional well-being, and dietary habits. Please fill out the following questionnaire as accurately as possible to provide us with a comprehensive overview of your overall lifestyle and health practices.
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Email *
Your Name:- *
Age *
How did you get to know about us? *
Required
Which State/Country you are currently residing? (It helps to know the seasonal food items available) *
Your current city *
Gender *
Marital status *
Height *
Weight *
Food habits *
My Nutrition knowledge is: *
Required
Have you ever consulted______________ lifestyle guidance / eating habits? *
Required
Do you drink alcohol? *
Do you smoke? *
Working / Occupation status *
Please share your work hours. *
Medical history / deficiency / complication (if any) *
Any medication you take, Yes/ No, and mention the dosage, if any *
Allergic to any food, Yes/ No, if yes, also mention the food *
Are your Menstrual Cycle normal? (only for females)

Pregnancy History you want to share (only for females)
Any digestive concerns *
Required
From the List below, What triggers you to eat/binge ? *
Required
How do you eat on a regular basis? *
Required
What do you think is reason for your weight gain? (optional)
How many glasses of water you drink *
Do you work out? *
I exercise, if yes *
Required
How would you describe your Exercise Habits ? (Check all that apply ) *
Required
What are the beverages do you drink usually? *
Required
If you skip meals, what meals do you usually skip? *
Required
What do you crave for most? *
Required
What are your top 3 favourite foods?

 *
What time of the day you are most hungry? *
Who prepare your meals at home? *
What are your sleeping patterns? Please include your wake up and bed time. Include weekday and weekend time also *
How often do you eat fast food or go out to a restaurant *
Number of family members staying *
How many meals you eat daily *
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