QUESTIONNAIRE

GENERAL DETAILS
• Name - A <tto~0- ~~1

• D.O.B. - 23 /en/, q!:>--s-

• Gender - boJQ_
• Phone no. - '1o9- "-13 ~12i°l o
e Alternate phone no. -
• Email address - -
• Residential address - C 1-J C 13 55" i
nd.
i/oo"' J ~ <.,..Ju.
• Ethnic background - P~]o.bi

ANTHROPOMETRIC MEASUREMENTS

• Height - 5 ~ ,. I 57 -'-i em

• Weight- G9 ~
• B.M.I. - 2"1.1 2-,.ci'1 ~I ~ci.

• I.B.W. - 52 ½
• B.M.I. Classification - OvV1we10U·
• r; tJ 82-- ~ I - .2-D n,o1 I 1c1 \ t3 \,J
1- o X 52- ::::. \O~ O \<..to.0 l~
..\u us~
2-5 KW\~ 1~W 2..5 1- 52- -= l :,oo lltc.0 t ~
lt~~

o.a)(52. - l..-\1. 6~1'Y"'

-tu
1 "'f.. 5.2.. - 5 2 j rn
 IOECONOMIC ST ATUS

• Birth place - Ha.'u10..Ae-

• Occupation - QLH~
• Type of family - AJ.u J e av-,
• No. Of family members - t,
• No. Of earning members - s
• Marital status - \.,Jrdow
• If married then no. Of children and their age - 1
~ e_ - ~2..

• If married then spouse's occupation - -

• Mode of commutation - ~ l,.jl\e.JQ)L

ACTIVITY PROFILE

• Any physical activity - ~ I/.) '-i o0a..

• Timing of activity - I 1/J.- h_ouJ,. b Ctm - 1:30 ~
• Do you go for a walk , if yes then at what time -
tvo

• During exercise, do you sweat more or less? - lL~

• Sleep hours - , - 8 koWv)
• Lying down hours - 1 - 2 kow-t/2
• What do you prefer stair or elevator? - 8evn.k)~
• Do you walk small distances? - AJo
 LIFICATION
5
• Degree - 12 ti- Pei 71 · µ c

MEDICAL HISTORY

• Personal history of obesity? - s~ne,t- ,~Q0-t.);Q_il

• Personal history of diseases? - rn.o~ -fu~n , ~:wQ.A¾iS9Dn,,

• Suffering from any disease? - 1--HG~ rQ))+<Ms 10-n

• If yes then which and medication for disease -

,~ Orv,~ or oJt, 0A oJ .., UM v talk-
1
• Any surgery/operation - TJ-r~n8r lortl
~(Jcz_

• Any specific food allergy - &ou.n ioDol 4nd. -{o ~1iu~.9cJ-

• Heredity if any? - AJoru.

DIETARY PATTERN

• No. Of meals per day - , +o f

1
• Vegetarian OR Non-vegetarian - VQjeJo..>, ~
• If vegetarian, then do you consume eggs? - ,u:)
• If non-vegetarian, then frequency of non-veg per
week-
• Frequency of following per day :
 1. Tea- 1- 2
2. Coffee - -
2
3. Milk - 1
-

4. Water - . , - 8 \ l&~~e-,
5. Fruit - 2 - 3 ',Q.),uln~

6. Salad - , - :i, 10-u "J

7. N uts - I - 2.. ,\-1!) "Iv,d C5!) "".,J1 l'"·' i)
8. Dried fruits - t0u
• Amount of sugar added in tea/coffee/milk - I ½p
• Do you add table salt - AJo
• Frequency of following per week :
1. Fried - 1 - .::,
2. Farsan - l - 2.
3. Packaged food - 1vo
4. Soft drink - fl)J
5. Sweets - \ - 2..
6. Chaat- \ - '2..
Fast food - t.J'J
7.
• Which cooking oil is used? - t·"hJ~MO-hd, 1~~cl(U}J
• Time taken to finish 1 bottle of oil? - 2. l..)e.~
• Do you consume ghee? - \/v.)
• Time taken to finish 1 packet of ghee? - 2 - 21 12.wm-1
• Likes - P..J,J.. /9(.JJH-~ eU.Uf f I /)l{uf'1t·· I J~c,... I ctc.h, b"1cJ.lo

• Di SI jk8 S - O ?to n Cf t
V I
a PY" Pa.. { .1 1
.,.,._OJl <7 r
~ Ocu, ( 09c/ H<~ . .
PSYCHOLOGICAL FACTORS

• Do you get stressed easily? - ·1u

• Do you cry often? - ~..o~rviM
• Are you satisfied with your life right now? - tJ 0
• Are you short tempered? - /0~
• Do you get worried easily? - '--!~
• Do you overthink? - 'i Qf.i
• Does your mood affect your diet? - '{~
• Heavy sleeper OR light sleeper - u h.t ~ o - ,
1
24-HOUR DIET ARY RECALL

Meal Menu lngredie Amt Energ~ Protein

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1

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+ l/'--1 ~r
000Brn. 50
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-3
Jo
100
-
2.. 5"
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Po+odu SD~ 5D 'l
 50 0
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5D 9-n-i SU
Po-to:lo L
Aloo ~o~1 i
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2=>
IDO
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p.o+i j_
2-0
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50 2--5
,S-
lur-ol 5
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T~CA \'1i QJ<. t- ~()_)"t

Snack~ 5Jwi 20
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f)q(\\"'IUi l'J-LQ,J\.6
100
p_ .5
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10 <0-5
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DIET CHART

""[iming Meal Menu

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