INFORMATION REQUESTED

1 Personal Details
Name
Contact No
email
address

2 Fitness Goal (can be any one or a combination of 2 or more)

Fat shed
Lean Muscle Gain
Imrove Energy Levels
Life Style Management
Diet Management
Any others - please describe

3 Current Body Stats

Gender
Age
Date of Birth
Height
Weight
Waist
Hip Circumference
Is there any specific body part that you are concerned about? Please describe

4 Current Health Parameters

Describe your general energy levels (and be specific about when you feel charged up &
when you feel low on a given day)
State of Digestion - do you typically feel bloated, gassy, sluggish, brain fog, less
focussed etc?
Do you find it difficult to get out of bed in the morning?
Do you feel like sitting more often during the day?
Do you feel drowsy during day time?
Would you consider yourself as having an irritable nature?
Would you say you typically take a lot of stress?

5 Current Lifestyle
What time do you sleep at night?
What time do you wake up in the morning?
Do you sleep soundly during the night?
Are you aware if you breathe through your mouth while sleeping?
Do you breathe through the nose or mouth during a walk?
Drinking - please describe any habits or tendencies.
Smoking - please describe any habits or tendencies.
Frequency of eating out in the restaurants or ordering in (weekly or monthly basis)
 How many times do you consume processed carbs like pizzas/burgers/sandwhiches etc
(weekly or monthly basis)?
How much water (in liters) do you drink in a day?
How many nights are you out attending parties/events leading to alcohol consumption
and/or eating out and/or late nights?
How many cups of tea/coffee in a day? ( please specify whether tea/coffee/both )
Please tell us if face any issues with drinking cofee? (eg acidity)
How many sodas do you consume? (Weekly or monthly basis)
Would you say your household (you and your immediate family members) has a
positive mindset towards health and fitness? Please share a line or two on the above.

6 Current Exercise Regime

Running (time/distance and freqency)
Walking (time/distance and freqency)
Gym (how many days in a week and duration)
Duration of sitting v/s standing in a given day

7 Current Food Habits (please be as accurate as possible)

Breakfast (what/quantiy/time)
Lunch (what/quantity/time)
Dinner (what/quantity/time)
Do you eat in between meals - please also specific what are these snacks.
Do you consume sweet dishes with yoiur meals or between meals? Typically, what are
these sweets?
Are you a vegetarian or non-vegetarian? Describe any other
habits/tendencies/practices.
If vegetarian - do you eat eggs?

8 Current Medications
BP
Sugar
Thyroid
Others
Do you consume any supplements? Please specify names and uses

9 Any major illness(es) in the recent past? Please describe

10 Any surgery(ies) in the recent past? Please describe

11 Foods that you feel you can't give up

12 Foods that you dislilke

13 Any known foood allergy?

 Please mix a spoon of Apple Cider Vinegar with a full glass of water and consume on
an empty stomach. Advise whether you experiencedany hot burning sensation in the
stomach.
14

How many breaths do you take in a minute? An inhale & exhale will be one cycle of
breath. Please assume a relaxed position,breathe the way you would normally do
and count.
15

Are you able to differentiate betweeen food cravings on account of emotions &
actual body hunger?
16

17 Which part of the body do you tend to accumalate fat first? (eg waist)

18 What is your resting pulse per minute?

On a scale of 1 to 5 with 1 being least & 5 being highest- what is the level of your
commitment to ensure the desired outcomes?
19

20 When breathless - do you open your mouth to breathe?

21 Any history of giddiness or vertigo?

22 In a minute how many breaths you take under normal conditions?

23 Please tell us which cooking oils are used at your home?

24 Do you have a cook at home or do you self cook?

25 Do you like quick & easy recipes or prefer elaborate ones?

26 Co-relations (if applicable)

Have you recently faced issues with bodyweight and an increase in injuries?
Have you started any new stretching protocol?
Are you presently practicing static stretching?
Have you ever made any changes in diet & noticed that you tend to injure yourself
more than before? Please elaborate any observations.
Does increasing muscles mass leave you more stiff than before?

27 Please describe your current state of health mentally & physically

28 How do you respond after eating a high carb meal?

Gassy, Bloated, Stomach cramps, Irregular bowels, No such symptoms
29 After eating carbs, how long is it before you feel hungry?
I feel hungry very soon & not satiated with my meal
I'm satisfied for about 60 minutes, but after that I feel like eating again
I'm fully satisfied for a few hours

30 How does a high carb meal affect your cognitive state?

I experience mental fatigue & brain fog
I have trouble focusing
I find no change in my mental abilities

31 How does a high carb meal affect your physical state?

Feel like taking a nap within 60 to 90 minutes of eating
Body feels very heavy & washed out
I'm absolutely stable

32 Which of these health conditions runs in your immediate family?

Diabetes, obesity, high triglycerides
None of the above

33 What of the below do you experience if you don’t eat every few hours?
Light headed, Irritable, Anxious
Light headed, Irritable, Anxious but I can deal with it after drinking water

I don’t experience the absence of food & sometimes I don’t even remember or feel the
need to eat food

34 Which of the below best describes your sugar cravings?

I crave sugars on daily basis regardless of what I eat
I crave sugards only during a particular time in the day
I crave sugars on on particular days in the month.
I don’t experience any cravings.
RESPONSES

Anay Patel
anay - 9054321177, sapna (mom) - 9825310703
sapnahpatel@[Link]
Maa bungalow, near dharnidhar cross road, vasana, ahmedabad 380007

yes
yes
yes
yes
yes

male
13 years
1st dec 2009
157 cm
67 kg
37.5 inches
41.5 inches
hips, thighs, waist, abdomen

usually low energy, feels tired easily

sometimes
yes, very much
yes
yes
no
no

around 10.30 or 11. On holidays, it is streched till midnight or even more

5.40 am on school days, otherwise around 8 or 9 am
yes
no
through nose
no
no
once a week
once a week

2 to 3 litres

none
none
n/a
none

yes, my mom gives the most priority to health and fitness

no
yes, daily one hour
none
I sit more often because half of the time I am in school or study classes.

dry fruit smootie or milk and cerials at 6 am (small bowl ) + breakfast in school break
1 or 2 roti and sabji or one bowl of dal rice at 1.30 pm .
roti sabji, pav bhaji, pulav, etc, at 8 pm

yes, in school, they provide different snacks, in evening I have makhana, chana, mamra, etc

not with meals but I have chocolates or cookies sometimes

vegetarian
I eat eggs, but its not allowed at home

no
no
no
n/a
no

last month I had dengue fever

no

french fries, chocolates, cookies

cucumber, capcicum, fruits except orange and banana

no
no

hips and waist

no

no

groundnut oil

cook

quick and easy, usually one pot meal

yes, I have put on more weight lately

no
no

no
no idea

no such symptoms
yes

yes

yes

yes, my dad has diabetes and high triglycerides but he is not obese

yes

yes
 80 27
100 33.75