General Health Assessment | Sonal Chowdhary

✦ Guided wellness section

Complete this section, then move to the next step.

Name

Date of Birth

Phone

Address

Age

Gender

Height

Current Weight

Current Medication

Medical History

Supplements / Vitamins

Food Allergies

Veg / Non-Veg Preference

VegetarianNon-VegVeganJain

Do you count or track calories?

Yes No

◉ Guided wellness section

Complete this section, then move to the next step.

Food Preoccupation5

Breakfast Appetite5

Lunch Appetite5

Dinner Appetite5

Eating Frequency5

Sour Food Enjoyment5

❋ Guided wellness section

Complete this section, then move to the next step.

Outline your eating schedule (wake up till sleep)

Typical Breakfast Details

Typical Lunch Details

Typical Dinner Details

Snacking Habits Between Meals

Alcohol Intake

Aerated Drink Intake

Coffee / Tea

Smoker Status

Stress Levels

Water Intake Per Day

Fast or Slow Eater?

Sleep Hours Per Night

Exercise Schedule and Frequency

Sitting Hours Per Day

Main Goal

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