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Admission Form
"
*
" indicates required fields
1
Basic Info.
2
Physical Health
3
Basic Questions
4
Improve Health
5
Stress Level
Full Name
*
Mobile No.
*
Email
*
Date of Birth
*
DD slash MM slash YYYY
Gander
*
Male
Female
Transgender
Address
*
Address 2
Occupation
*
Service
Business
Retired
Measurement types
*
cm
inch
Foot
Height
*
Measurement types
*
kg
Weight
*
Age
*
Blood Group
Blood Group
A+
A-
B+
B-
O+
O-
AB+
AB-
My Physical Health Goal
*
Weight Loss
Fat Loss
Muscle Gain
Weight Gain
Improve Sleep Quality
Other (Please Describe)
Other Details
Do you feel you've always had a weight problem?
Yes
No
If yes, around what age did you first notice that you had gained weight?
What do you feel your weight gain caused by?
Have you ever had any health problems as a result of dieting?
Yes
No
If Yes, What Problem?
Please list any surgeries you've had.
Do you Smoke?
*
Never
In The Past
Currently
Quantity
Frequency
Frequency Smoking text
Alcohol use?
*
Never
In The Past
Currently
Quantity
Frequency
Frequency Drink text
On average how many hours of sleep do you get?
What diets have you tried in the past?
To improve your health, how ready/willing are you to...
[ On a scale of 1 ( Not Willing ) to 5 ( Very Willing ) ]
(A) significantly modify your diet
1
2
3
4
5
(B) Take nutritional supplement each day
1
2
3
4
5
(C) keep a record of everything you eat each day
1
2
3
4
5
(D) Practise relocation techniques
1
2
3
4
5
(E) engage in regular exercise/physical activity
1
2
3
4
5
physical activity
(A) Strength Training
None
Low
Moderate
High
(B) Cardio / Aerobics
None
Low
Moderate
High
(C) Stretching / Yoga
None
Low
Moderate
High
(D) Sports or Leisure
None
Low
Moderate
High
Indicate the level of stress from 1 (extremely low) to 10 (extremely high)
Work
Family
Social
Financial
Health
Other Specify
(A) Water in take (Per Day)
(B) Cooking medium (Choice of dietary fats/oils)
Intense dislike towards
Highly sensitive to
Your Meal may include,
Milk
Curd
Paneer
Cheese
Egg
Chicken
Fish
Right time to speak to you on call or message
Hours
:
Minutes
AM
PM
AM/PM
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