Nutrition Assessment and Lifestyle Evaluation Form

Gender
MaleFemale

Are You Pregnant?
YesNo

Medical History / Lifestyle Disorders

Excess WeightUnderweightDiabetesCardiac (Heart disease)High CholesterolHigh Blood PressureBone/ Joint ProblemsArthritisThyroid diseaseHigh Uric Acid (Gout)HerpesAllergiesAsthmaEating disorderEpilepsyAlcoholism/ Drug AddictionEar, nose, eyes, throat problemsGastroesophageal reflux diseaseIrritable bowel syndromeHypersensitivitySinus problemsOsteoporosisMigraine headachesDepressionPremenstrual Syndrome (PMS)Menstrual irregularitiesMenopausePCODSexually transmitted diseaseSkin problemsGall StonesKidney Stones

Specific food restrictions:

LactoseGlutenOil / FatSaltProteinsSugar/ CarbohydratesFood Allergies

Basic Anthropometrics:

Circumference

Activity Level* (Tick the right one):
SedentaryModerateHeavy
Food Pattern (Tick the right one):
VegetarianNon-vegOvo-vegetarian




Any Food Likes and Dislikes:
YesNo


Do you eat out?
YesNoSometimes

*Classification of Work based on Profession Sedentary (mainly deskbound jobs): Teacher, Tailor, Barber, Hair dresser, Executives, Shoe maker, House wife, Priests, Nurses, Land lords, Doctors, Peon, Postman, Bank Managers, Lawyers, Engineers,

Moderate Fisherman, Maid-servants, Potter, Basket maker, Goldsmith, Weaver, Agricultural Labour, Coolie, Carpenters, Mason, Rickshaw-puller, Electrician, Fitter, Welder, Industrial Labour, Weaver, Driver

Heavy Stone Cutter, Black smith, MineWorker, Sports-women, Wood- Cutter, Gangman Sports-men

Digestive Issues:

Any digestive problems?
YesNoSometimes

Constipation
YesNoSometimes

Diarrhoea/ Loose Motions
YesNoSometimes

Gas / Flatulence
YesNoSometimes

Daily Dietary Pattern

*Specify amounts in teaspoon, tablespoon, katori size (average katori size is 150-180 ml), cup sizes (average cup size is 150 ml), numbers (e.g. 2 phulkas, 4 idlis, 1 dosa, 2 uttappas)

Meals (specify timings)

Food Consumed*

Amount/ Quantity*

Early Morning

Breakfast

Mid-morning

Lunch

Evening

Mid-evening

Dinner

Bedtime

Additional Questions:

Do you eat fruits?
YesNo

Alcohol:
YesNoSometimes

Smoking:
YesNoSometimes

How much water do you drink?

Food Frequency Questionaire
How often do you eat the following foods per week?

Food items

Times per week

Food items

Times per week

Eggs

Bread

Beef / Mutton

Rice

Chicken

Pizza

Fish

Sweets

Turkey

Ice Cream

Cottage cheese (paneer)

Beans (Rajma, Chole, Mung, sprouts etc)

Cheese

Aerated drinks

Soya

Alcohol

Oats

Vegetables

Instant frozen foods

Margarine/Butter

Fruits

Fruit Juices

Oil Consumption for the family

How many people are there in your family?

Sugar Consumption of the family

Specify how many people in the family consume sugar?

Jaggery Consumption

Ghee Consumption

Butter Consumption

Exercise

Do you Exercise?
YesNoSometimes
Type of Exercise

How often?

How long do you Exercise?

What time do you exercise?

Cardio Or Weight Training or Both?

Specify exact type of exercise
Treadmill

Duration

Cycling

Duration

Functional Training

Weight Training

Any other

I, hereby declare that all the information disclosed by me to Ambrosia Wellness about my diet, supplements, medicines, diseases, pathology and laboratory reports, any other medical or diagnostic results is truthful and to the best of my knowledge. Ambrosia Wellness is not responsible for any adverse circumstances if they were to arise, out of non-disclosure of health information and/or disease conditions by me.
I will not share, sell or distribute any of the material or solution customized for my needs with any other outside person. I shall consult a doctor for qualified medical advice, diagnosis or treatment. It is important for me to understand that Ambrosia Wellness does not provide medical/ drug advice, diagnosis of disease, treatment for a complete cure of any disease or ailment.

Receiver ‘s Signature: