Customized Diet plan Questionnaire

Customized Diet plan Questionnaire

Answer questions in as much detail as possible, More details you provide more better it is !!
Name *

First Name Last Name
E-mail *
enter your email address here.
Contact number *
we will contact you on this number
Diabetes Diagnosed on *

Month Day Year
Age *
how old are you?
Gender *

Male Female
Height *
what is your height ?
weight *
what is your weight ?
waist size *
what is your waist size ?
Eating habit *

Do you smoke? (select 0 if you don't smoke & select 10 if you smoke heavily) *

	0	1	2	3	4	5	6	7	8	9	10

0 is I dont smoke, 10 is I smoke heavily

Do you Drink Alcohol ? (select 0 if you dont drink and select 10 if you drink heavily) *

	0	1	2	3	4	5	6	7	8	9	10

0 is I dont drink, 10 is I drink heavily

Mother Tongue
Home town
Present Residence
Your Profession
Does your profession involve Sitting ? if yes how many hours a day *
How many hours do you work with computers everyday ? *
How many meals do you eat /day. *

1 2 3 4 5 6 >6
How much do you eat ?
At what time do you wake up in the morning? *

: Hour Minutes AM/PM Option
At what time do you Sleep at Night? *

: Hour Minutes AM/PM Option
What is the first thing you do after you wake up.
Tell me everything you do between wake up and breakfast.
What do you eat in Breakfast generally? *
What do you eat in Snacks generally? *
What do you eat in Lunch generally? *
What do you eat in Dinner generally? *
Foods you eat often (select foods you eat more than 3 times a week) *

Biscuits channa Dry fruits Dates vada pav vada pani puri home made snacks bakery items dosa idli parota roti white rice brown rice fried vegetables salads Almonds walnuts cashews pistachios puffed rice poha chiwda green smoothie apple cider vinegar green tea milk tea milk coffee black tea black coffee herbal tea Fruits Chips cakes samosas fried items Haldiram packets Maggi noodles coconut
Please tell us your top 5 favourite foods *

Please mention your test report readings, if you are not able to fill this readings, please upload scanned copies /pics of your medical reports below. *

	Readings / value
Fasting Blood Sugar levels
Post Lunch Blood Sugar levels
HBA1C
C Peptide
Fasting Insulin Levels
Post Prandial Insulin Levels
Triglycerides
HDL Cholesterol
LDL Cholesterol
VLDL Cholesterol
Lipoprotein -A
Testosterone
Vitamin B
Vitamin D
Calcium
Iron
blood pressure
oral glucose tolerance test
C Reactive protien test
PPBS
Total Cholesterol
C PEPTIDE
Urine Test
Creatinine
TSH (thyroid)
Gluten sensitivity
Ast/sgot (liver)
Alt/sgpt (liver)
Lactate dehydrogenase

If you are not able to fill the details above you can upload your medical reports here.
What Makes you worry about your Diabetes? *

Not able to eat your favourite food Not able to enjoy at parties / Marriages or special ocassions Feeling lazy and lethargic all the day Eating out side makes my diabetes worse uncontrolled blood sugar levels after food uncontrolled fasting blood sugar levels decrease in sexual libido diabetic foot
Other Health Complications? *

Dental problems blood pressure high cholesterol Arthritis / joint pains Thyroid sexual problems Gluten Sensitivity fatty liver Constipation piles Digestive disorders
Anything else you want me to know?
How did you come to know about us *

facebook A friend told me Google