Health Assessment Basic Information Fitness level life styles Health Concerns Medical history Goals Basic Information 1 How young are you? 2 What is your gender? Male Female 3 Please enter your height (in feet) : 4 Please enter your weight (in kg) 5 Are you Vegetarian Non Vegetarion Vegan Fitness Level 6 Usually how many kms do you walk in a week? less than 10km between 10-20 km More than 20 km 7 Can you continuously run for 3 mintues moderate speed? Yes No 8 Do you experience any joint pain while running Yes No life style 9 In a month, how often do you travel outside the city for work/meeting No travel less than 7 days between 7-15 days More than 15 days 10 On a scale of 1-5 how stressed you feel everyday ( 1-very low, 5-high) 5 4 3 2 1 11 Do you smoke Yes No 12 In general, please rate ( 1-donot feel refreshed | low energy, 5-feel completely refreshed | highly energetic ) How refreshed you feel when you wake up 5 4 3 2 1 How energetic you feel throughout the days 5 4 3 2 1 Health Concerns 13 Do you have any of the below symptons currently Yes No hair loss Body Pain/ Backache Bloating/ Constipation/ Drarrhoea/ Stomach Pain Eyes-strain/ Blurred Vision Feel Dizzy Unexpected weight loss/ weight gain Frequent Coughing 14 How often you fall sick on a month i usually don't fall sick Once twice a month Once twice a week I feel sick everyday Medical history 15 Do you/ anyone in your family has any of the following medical condition I have My family members have Drabetes - Type 1 Drabetes - Type 2 High Blood Pressure high choresterol Reumatord Artherthis Cardiovascular Disease Thyroid PCOS IBD/ IBS/ Crohens/ VC Artherthis Cancer Goals 16 What are your health goals? (Please select any three) Vitality & Sexual Anti-agering/ longexity Skin & hair-care feeling energetic loose weight Achieve fitness portentail Stay Disease free improve Mental Function Name: Email:
