Q-1 Are you having
any of these?
|
Disorder
|
Yes / No
|
Medication for same
|
|
Hypothyroidism
|
|
|
|
High Blood Pressure
|
|
|
|
Diabetes Mellitus
|
|
|
|
Hypercholesterolemia
|
|
|
|
Hormonal Disturbance
|
|
|
|
Depression
|
|
|
|
Irregular Period (For Females)
|
|
|
|
Asthma
|
|
|
|
High Uric Acid (Hyperuracemia)
|
|
|
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Arthritis / Joint Pains |
|
|
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Any Other |
|
|
Q-2
Did you had any one of the above listed disorders ever in life time for a short
while?
If Yes which one -
Q-3
Any Surgery ever?
Q-4 If you are a married female (otherwise ignore)
Q-5 Do you have history (Mother / Father / Maternal or Paternal Pools) towards any disorder
like –
Q-6 Do you have any allergy with any Foodstuff?
Q-7 If you weight Loss or weight Gain patient, have you
tried anything before
Q-8 Do you have any activity right now like :
Q-9 What is your daily diet pattern of what you eat & how much?
Q-10 How frequently do you eat out?
Q-11 Do you smoke?
Q-12 Do you consume Alcohol, If Yes how frequently / How
much?
Any Suggestions / Query