Dr Sumaiya's Patient History Form
Please set aside at least 25 min to fill this form. Give as much details as possible. Don't fill it in haste , strictly follow the examples provided in the questions

This form will help us get a better understanding of yourself for better diagnosis and will also help a lot to uncover any problems.
Questions marked * are compulsory.

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Name *
Gender *
email *
Address *
to get some idea of locality
Mobile *
Height *
in cm without appending units eg:165
Weight *
in kgs without appending units eg:60
Education *
Age *
Your activeness? *
rate your physical activeness from 1(little physical activity) to 5 (very active)
Sedentary (eg: Mostly sitting throughout the day, not much physical Activity)
Very Active eg: 40 min of strenous physical activity/day
Chief complaints / Problems *
Enter main problems you face eg: Obesity, Hypothyroidism, Constipation, Body aches,
Do you want to Gain weight or Lose weight *
Note down these three measurements and fill it out below:
Waist size cm *
Measured from the narrowest part of sides and passing through belly button only in  centimeters between 50 and 200
Hip size cm *
Measured from maximum circumference in  centimeters
Mid upper arm circumference of right hand cm
Medical History
History Present Illness *
History Present of Illness eg: Fever, Insomnia etc Please give all details with report values eg: Viral fever: 99 F
History of chronic(prolonged, permanent) Illness *
eg: Diabetes, Blood Pressure etc  Please report all values  eg: Diabetes sugar 110,  BP 90 etc
Medications taken currently *
you can also specify anyAlopathic, Ayurvedic remedies, supplements, protein powder etc you might be taking
Dietary History
Diet schedule in a day:  Breakfast time and breakfast foods *
Lunch time and food *
Dinner time and food *
Snack time and foods you take in snack 1 *
Snack 2 time and food items *
Cusine followed mostly *
Gujrati, South Indian, Punjabi, American etc
Are you doing any exercise *
Special Diet requiement ? *
eg: Are you a Vegetarian, diabetic, BP ...? check all that apply to you
Allergies? *
Who prepares the majority of your meals? *
Who shops for food? *
Dental and oral health problems?
Did you have Recent weight changes: Loss/gain How much _____ kgs. *
eg: Lost 2kg this month , do also specify  the duration in which you saw weight change eg: gained 5 kg in 2 weeks
The food/nutrition questions that I would like to ask are , or general information to convey:
Are you employed or go out for Education etc , if yes then what are your working hours and lunch \break timings and what is your work profile i.e (sitting, fieldwork etc)? *
eg:Yes working 8am to 9pm , short break 11am -11.30 am , lunch at:1.30 pm-3pm , working mostly sitting on computer
Lifestyle Habits *
Check all that apply
Number of family members *
How many members in your family
Amount of oil consumed per month in Kgs in the household *
eg: 0.75 kg per month, enter only value
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