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Meesha Clinic, Mahalaxmi | Zahra Worli, Mumbai
Mon-Fri:10:00-18:00
pallavi@ambrosiawellness.com
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Assessment & Guidance (no diet plan)
Name
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Date of Birth
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Age
Gender
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Male
Female
Phone
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Email Address
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Your Occupation
Address
Medical History / Lifestyle Disorders
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Select
Excess Weight
Under Weight
Diabetes
Cardiac (Heart disease)
High Cholesterol
High Blood Pressure
Bone/Joint Problems
Arthritis
Thyroid Disease
High Uric Acid (Gout)
Herpes
Allergies
Asthma
Eating Disorder
Epilepsy
Alcoholism/Drug Addiction
Ear, Nose, Eyes, Throat Problem
Gastroesophageal Reflux Disease
Irritable Bowel Syndrone
Hypersensitivity
Sinus Problem
Osteoporosis
Migrane Headaches
Depression
Premenstural Syndrone (PMS)
Menstural Irregularities
Menopause
PCOD
Sexually Transmitted Disease
Skin Problems
Gall Stones
Kidney Stones
Other
Any illness/ Past Surgeries? If Yes, when?
Do You Fall ill Easily?
Specific food restrictions:
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Lactose
Gluten
Oil/ Fat
Salt
Proteins
Sugar/ Carbohydrates
Food Allergies
Other Food Allergy
Medications (specify names, timing of medication and reason you taking that)
Height (cm)
*
Weight (Kg)
Waist Circumference (red line) (Cm)
*
Usual Weight
*
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*
Food Pattern
Veg
Non Veg
Vegan
Ovo Veg
If Non veg / Egg intake - How many times a week/ month
*
Food Pattern
*
Sweets
Fried Foods
Alcohol
Smoking
Diet Recall ( Early Morning )
*
Diet Recall ( Breakfast )
*
Diet Recall ( Mid-Morning )
*
Diet Recall ( Lunch )
*
Diet Recall ( Evening )
*
Diet Recall ( Mid Evening )
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Diet Recall ( Dinner )
*
Water Intake
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Exercise
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Additional Recommendations
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