Naturecure by ruhi


Naturecure by ruhi
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Naturecure by ruhi


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Client lifestyle form (Age 13-17 years)

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SL No Blood Work (Marker Name) Date: Date: Date:
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Daily Routine, Food Habits & Lifestyle

Morning Field Details
Wake up
Activities
Breakfast
Afternoon Field Details
Activities
Lunch
Activities
Evening Field Details
Evening Drink / Snack
Night Field Details
Dinner
Night Routine
Sleep
Food Habits Field Details
Veg / Non Veg / Vegan
Outside Food
Favourite Food
Allergies
Smoking
Alcohol

Nutrition and Lifestyle screening questionnaire

1. Do you feel the need to lose or gain weight:

Lose weight Gain weight

2. Do you regularly skip meals: Breakfast, Lunch, dinner)

Yes No

Why do you skip meals-


3. Do you sometime eat to a point where you feel uncomfortable or out of control:

Yes No

4. Do you think food lifestyle you currently following healthy?

Yes No
Why do you think that way:

5. Do you watch phone, tablet or TV while eating food:

Yes No

6. How much time do you spend on screen every day (Give hours):


7. How much is your water intake: (Mention in glasses or litres)


8. Do you have trouble in sleeping:

Yes No

9. Do you wake in between at night to eat food:

Yes No

10. How many hours of sleep do you get:


11. Do you binge eat at anytime of the day or night:

Yes No

12. Do you have any issues with digestion

       



13. Do you do any physical activity on regular basis:

Yes No



14. How many hours do you give for physical activity:


15. Do you feel it is important to lead healthy lifestyle:

Yes No

16. Please mention few food items you eat which you consider unhealthy


17. Please mention few items you eat which you consider healthy


Hormone Panel

LPD:
 Period Cycle:
 Bleeding Profile:
 Nutritionist Analysis
Condition Location Symptoms Scans (USG/TVS/MRI) & SIZE Gut Symptom Mapping

Current Medication

Other routine checks

Gut Health
Skin
Appetite
Sleep
Energy level
Emotional Well being
Mental Well being
Others

Do's and Don't

Do's Don't

Diet Advise

Post Wake Up
Breakfast Options
Mid Meal Options
Lunch
Evening
Dinner
Post Dinner

Supplements

Supplement Name Dosage Timing / Instruction Action







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