8/12/2019 Preventive Wellness Client Consultation Form

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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:

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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

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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 itsconsequences and none of the person shall be liable on account of my joining the program.

Mail this file to datta.abhimanyu@gmail.com