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You are what you eat,’ goes the saying and therefore you try to eat healthy foods.
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MEDICAL FORM
 
The doctor’s weight-loss clinic
 
Date
Name
Age
Address
Occupation
History of Weight Gain
Telephone
Email*

Clinical Examination

Anaemic
BP
Oedema   (any swelling)
Blood group
Distribution of Fat (areas)
Family History
Diabetes
CAD   (heart problem)
Arthritis 
Obesity
Medical History

Constipation

Acidity/gas

Cervical/spondilitus

Sinus/migrane

Menstrual History (for women)

Having any medications?

Measurements

Height

Weight
Abdomen
Chest
Waist 
Hips

History of Weight Loss Efforts

Methods or weights loss program used before

How much they lost

Physical activity

VEG. / NON-VEG

ROUTINE DIET (With Timings)

Break-fast

Lunch

Evening Tea:

Dinner

After Dinner

FOOD FONDNESS:

FOOD DISLIKE:

ALLERGY:

SWEET TOOTH:

LIFE STYLE:   

HUNGER TIME

ENERGY LEVEL
DIGESTION
SLEEP CONDITION

MEALS OUT IN A WEEK

ALCOHOL