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Weight Loss
Weight Loss
Quick Weight Loss
Fat loss Diet
Life Style Counseling for obese Women
Name * :
Occupation :
Address :
Contact No * :
Email ID * :
Age * :
Current Weight (in kgs) * :
Actual Weight (in kgs) - Last 3 months * :
Height (in cms) * :
Hunger * :
Un-Satiated Early Satiated
Urination * :
Increased urination Decreased urination Frequent urination during night time Normal
Bowel * :
Loose stools Diarrhea Normal
Diet * :
Vegetarian Non - Vegetarian Ova Vegetarian
Food Frequency (Per Week)
Cereals * :
Pulses * :
Vegetables * :
Fruits * :
Greens * :
Egg * :
Meat (In detail) * :
Milk * :
24 Hours Recall (Please Specify)
  Time   Item   Quantity
Wake up Time *    
Morning *    
Breakfast *    
Mid morning *    
Lunch *    
Evening *    
Dinner *    
Bed time *    
Physical activity * :
Walking Jogging Gym Aerobics
Other sports Yoga Swimming Sedentary
Activity level * :
Beginner Intermediate Advanced
Duration * :
Family history of obesity :
Father Mother Siblings
Medical history :
BP Diabetes Cardiac Issues Skin Allergies
Skin Allergies PCOD (polycystic ovarian disease) Hormonal Imbalance
(Please specify if any) :
Medications (Please specify if any) :
   
Fat loss Diet
 
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