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Nutritional Assessment Form
(Providing the following information will allow a better understanding of your condition and enable us to help you better.)
Personal History
Name:
Age:
Gender:
Height:
Weight:
Weight last year:
Medical History
Do you have a medical history?
If yes, please specify:
Lifestyle Profile
What is your occupation?
How many hours a day do your work?
If yes, please specify.
Activity level
Do you exercise
If yes, how often do your exercise?
Type of sport you play
Duration
Diet History
Are you a vegetarian or non-vegetarian?
Are you following any special diet?
Any Other
Do you smoke?
If yes, please specify.
Do you drink?
Are you taking any supplements?
If yes, please specify.
How many times a day do you take them?
How many liters of water you consume in a day?
Goal Settings



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