Best Dietitian & Nutritionists in Gurgaon

Name:*

Contact Number:*

Email Address:*

Have you tried to lose weight or make lifestyle changes in the past?

Yes No

Do you do exercise?

Yes No

How many hours you sleep in a night?

5-6 hours 7-8 hours none of the above

Do you expose your skin to sunlight?

Yes No

Do you currently take any vitamins or supplements?

Yes No

Do you smoke?

Yes No

Do you have any food allergies or food intolerances?

Yes No

How often do you eat fast food or go to a restaurant?

0‐1 times/month 2‐3 times/month 1‐2 times/week 3‐4 times/week 5+ times/week

How often do you drink alcohol?

0‐1 times/month 2‐3 times/month 1‐2 times/week 3‐4 times/week 5+ times/week

How much water should you take per day?

4-5 glasses 9-10 glasses

Are you happy with your weight?

Yes No

What is your current stress level?

Moderate High

Do you feel pain in your body?

Yes No

What is Current Health Problems

Diabetic Cholesterol

Do you crave sweets?

Never Occasionally Often

Do you face the problem of brittle hair or facing hair loss?

Yes No

Do you have skin rashes or any other issues that just don’t go away?

Yes No

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