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
Date Picker Icon
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
*
Option Vegetarian
Option Eggitarian
Option Non vegetarian
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
I dont smoke
I smoke heavily
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
I dont drink
I drink heavily
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
*
more than 2 hours
more than 4hours
more than 6 hours
more than 8 hours
How many hours do you work with computers everyday ?
*
more than 2 hours
more than 4hours
more than 6 hours
more than 8 hours
How many meals do you eat /day.
*
1
2
3
4
5
6
>6
Other
How much do you eat ?
Stomach full
Half empty
more than 80 percent
no control
At what time do you wake up in the morning?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
At what time do you Sleep at Night?
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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
Other
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.
*
Rows
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.
Upload a File
Cancel
of
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
Other Health Complications?
*
Dental problems
blood pressure
high cholesterol
Arthritis / joint pains
Thyroid
sexual problems
Gluten Sensitivity
fatty liver
Constipation
piles
Digestive disorders
Other
Anything else you want me to know?
How did you come to know about us
*
facebook
A friend told me
Google
Other
SUBMIT YOUR ANSWERS
Back
Next
Should be Empty: