NUTRITIONAL CLINIC

Clinical Intake Assessment

Please answer these detailed physiological and dietary questions accurately so we can customize your metabolic blueprint.

1. Demographic Info

Full Name *

Date of Birth *

Gender *

WhatsApp Number *

Email Address *

Occupation

Address & City

3. Clinical Details & Lifestyle

Present Health Conditions / Diagnosis

Past Medical History / Surgeries

Family Medical History

Current Medications

Supplements Taken Currently

Food Allergies, Intolerance, or Dislikes

Work Mode

Work Shifts

Physical Activity Level *

Average Sleep Duration (Hours) *

Perceived Stress Level

Daily Water Intake (Liters) *

4. Dietary Pattern & 24-Hour Recall

Dietary Preference *

24-Hour Recall (Describe what you ate yesterday & quantities):

Early Morning Food

Quantity / Cup Size

Morning Breakfast Food

Quantity

Mid-Morning Snack Food

Quantity

Afternoon Lunch Food

Quantity

Evening Tea/Snacks Food

Quantity

Dinner Food

Quantity

Bedtime Food / Milk

Quantity

Dietary Habits & Frequency:

Outside Food / Dine-out Frequency

Junk Food Frequency (Deep Fried / Fast Food)

Sweets, Chocolates, or Desserts Frequency

Tea / Coffee Frequency (Daily Cups)

Do you currently suffer from any of these? (Select all that apply)

Bloating / Gas Constipation Acidity / Acid Reflux Chronic Fatigue / Low Energy Sugar/Salt Cravings Frequent Headaches

Other Symptoms or Complaints

Your Main Goals / Expectations from this program *

Clinical Intake Assessment

1. Demographic Info

2. Physiological & Anthropometric Data

3. Clinical Details & Lifestyle

4. Dietary Pattern & 24-Hour Recall

Assessment Submitted