Enquiry Form

HDS Enquiry Form

Please fill it sincerely and without missing any information to analyze your diet pattern

Name *

Phone *

Email Address *

Age *

Gender

Height (in cm) *

Weight (in kg) *

Are you a *

Query / Compliant *

Occupation *

Wake up time & Bed Time *

How often do you eat these and how much? (In ml or grams)? *Milk, Curds, Buttermilk, Paneer, Butter, Cheese

How often do you eat these (Chicken Mutton Beef Pork Fish Prawns Eggs ) and how much? And Specify the form which you eat - Fried, Baked, Roasted or Grilled *

How often to do eat Green leafy vegetables like spinach, fenugreek leaves, mint leaves, Amaranthus leaves and how much? *

How often you include vegetables in your diet and how much? *

How often do you include potatoes, yam, sweet potato in the diet, how much you include, in what form do you eat(deep fried, shallow fried, curry form)? *

How often do you consume fruits, which fruit and in what form? (Mixed salad, fruit juice, shakes) *

How often do you include split dals like Tur dal, Urud dal, Channa dal and how much? *

How often do you include Whole gram pulses like Rajma, Lobia, Channa, any other pulses and how much? *

How often you include Wheat, Ragi, millets in food and how much? *

How much of oil do you purchase for a month and what are the different kind of oils you purchase at home? *

How much of Sugar do you use for a month? *

How many members stay at your home? *

How much of water do you drink in a day? *

Do you drink tea(black, green), coffee, Horlicks or any such health drinks? How much you drink (in ml) and when do you drink (what time)? *

Do you dine out? How frequently you dine out? *

How often you eat fried foods and chats? *

How often do you eat sweets? *

Do you smoke, consume alcohol? If yes, specify: *

Any Food Allergy? *

Any Medical Issues? *

Any Medications? *

Do you exercise, How long do you exercise and what exercise do you do? *

If you are stressed, what do you do to relieve yourself from stress? *

24hour-Diet Recall: (From yesterday’s wake up time till bed time, tell me as what did u eat for breakfast, lunch and dinner, and in between if you have had something and your activities) *