Enter your personal info
Enter your Basic info
Does any of your family members (father, mother, brother, sister, aunt or uncle)
have any of the following diseases
Do you have any of the following diseases/conditions:
Answer this question
Do you have any food aversions/allergies?
Do you have any food intolerances?
When was the last blood tests done? If you have, please send it along with this assessment
Do you take any medications/supplements
Do you consume Alcohol? If yes how frequent and which drink?
For females: Is your period usually on time? Do you have PCOS or any other feminine conditions?
How many hours of sleeping do you get per day?
What is the Highest weight you have reached and when?
What is your Lowest weight you have reached and when?
What do you think about your daily eating habits and life style?
Did you follow any kind of diets or meal plans?
What kind of Diet? And for how long?
Did you find it effective? And were you satisfied?
How many kg’s did you lost/gain?
Lifestyle/Eating Pattern and Habits:
How many meals and snacks do you consume per day?
Select the meals you frequently consume the most per day:
How much water do you drink per day? (Cups/Litters)
How many times (per week) do you consume Fruits ?
How many times (per week) do you consume Vegetables (salads, cooks and raw vegetables)?
How many times (per week) do you consume Milk/Cheese/Laban/Labneh and by products
How many times (per week) do you consume Meat
How many times (per week) do you consume Chicken
How many times (per week) do you consume Fish and any byproducts
How many times (per week) do you consume Junk Food? (Pizza, burgers, fries, nuggets and etc.)
How many times (per week) do you consume Desserts and Chocolates
How many times (per week) do you drink Fresh Juices/Red-bull/Canned Juices
How many meals per day you consume (Bread/Toast/Rice/Pasta or Potato)
What is your regular portion of the below mentioned food items per meal?
(Tablespoons or any appropriate measurement)
What is your favorite method of cooking?
Do you prefer homemade food or outside foods?
Do you add salt to your food?
What are your favorite sauces?
Do you have sugar cravings?
Are you an emotional eater?
Any additional food habits you would like to mention and add?
Do you practice any physical activity?
how many times per week, for how long and what kind of physical activity you do?
24 Hour Recall:
In this part, please write down what do you have on your regular days,
For example: you wake up at 7 am and you drink a cup of black coffee without sugar, and at 9.30 am you have a labneh sandwich, and in between the meals you had an apple… etc.
Other Notes You Would Like to Add Up? Or any other food habits/preference you would like to share with me:
Please take the measurement of the marked areas shown in the photo,