NAME *

AGE *

HEIGHT *

WEIGHT *

BMI *

WAIST *

HIPS *

W/H RATIo *

TOTAL FAT *

VF *

FAT MASS *

FAT FREE MASS *

MUSCLE *

BONE WEIGHT *

CALORIE INTAKE *

OCCUPATION *

WORK SHIFT *

NO. OF SKIP MEALS *
Yes No

IF YES,WHICH MEAL DO YOU SKIP? *

DOES PATIENT USE ARTIFICIAL SWEETENERS? *
Yes No

NAME OF ARTIFICIAL SWEETENER? *

DO YOU TAKE DIABETIC FRIENDLY FOODS ? (VEG & FRUITS) *
Yes No

DO PATIENT HAVE ALLERGY/INTOLERANCE OF ANY FOOD? *
Yes No

IF YES, NAME OF ALLERGIC FOOD *

FOOD HABITS *
VEG NONVEG OVO-VEG LACTO-VEG

NUTRITIONAL SUPPLEMENTS *
Yes No

IF YES ,NAME OF SUPPLEMENT *

AMOUNT OF OIL USED PER MONTH IN MLBY WHOLE FAMILY *

NUMBER OF PEOPLE AT HOME *

APPROXIMATE OIL INTAKE PER DAY IN TSP *

NUMBER OF MAJOR MEALS IN A DAY *

NUMBER OF MINOR MEALS IN A DAY *

WATER INTAKE IN A DAY *

DOES YOUR OCCUPATION REQUIRE SHIFT CHANGE ? *
Yes No

PLEASE DESCRIBE *

MILK USED AT HOME (MILK NAME) *

AVERAGE MEAL EATEN OUTSIDE * Daily Weekly Monthly Occas.

ALCOHOL INTAKE. *
NON-ALCOHOLIC EX.-ALCOHOLIC (>1 YEAR) SOCIAL DRINKER HEAVY DRINKER [ WOMEN (> 8 DRINK/WEEK) ] [MAN (>15 DRINK /WEEK)] 1 DRINK=30ML. , 1 BEER=250ML

SMOKING *
NON SMOKER EX. SMOKER (>1 YEAR) LIGHT SMOKER (<10 /DAY) MODERATE SMOKER (10-20 CIGARETTE/DAY) HEAVY SMOKER (>20 CIGARETTE/DAY)

TOBACCO *
NON-TOBACCO CHEWER EX.-TOBACCO CHEWER (>1 YEAR) LIGHT TOBACCO CHEWER (<5 GM./DAY) MODERATE TOBACCO CHEWER (5-10 GM./DAY) HEAVY TOBACCO CHEWER (>10 GM. /DAY)