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About Us
Services
Gallery
Contact Us
Register Now
NYHS Registration Form
Your Health Information
Pregnancy Feedback Form
Client Feedback Form
About Us
Services
Gallery
Contact Us
Register Now
NYHS Registration Form
Your Health Information
Pregnancy Feedback Form
Client Feedback Form
Menu
About Us
Services
Gallery
Contact Us
Register Now
NYHS Registration Form
Your Health Information
Pregnancy Feedback Form
Client Feedback Form
Your Health Information
Name
Age
Weight
Select if you have any of these complaints:
Acidity/ Gas
Uric Acid
Constipation
Irritable Bowel Syndrome
High Blood pressure/ hypertension
Heart disease
Low blood pressure
Palpitation
Cholesterol
Diabetes
Thyroid
Swelling of hands/feet
Cervical Spondylosis
Hormonal imbalance
Irregular periods
PCOD
Infertility
UTI
Uric Acid
Arthritis
Asthama
Epilepsy
Hernia
Skin Allergy
Metal implant
Eczema
Surgery
Ulcers
Anemia
Any other
Do you complain pain anywhere in body
Lower back pain
Knee pain
Neck pain
Fingers joint
Rate the degree of your pain in 0 degree to 10 degree Scale (Zero means none and 10 is the highest)
Are you on any medication? If yes, mention for which thing (it may be disease, pain or nutrient supplement)
1. I am overweight since __year/s, __ months.
2. I feel I am overweight/ obese because of
Overeating
Surgery/ Pregnancy
Sedentary lifestyle
Drugs
Wrong kind of eating
Heredity
Other
3. My lifestyle is
sedentary
moderate
active
4. I am a
Vegetarian
Non-Vegetarian
Eggetarian
Vegan
5. My favorite meal is
Breakfast
Lunch
dinner
Mid-morning
Evening Tea
6. I skip
Breakfast
dinner
Lunch
7. I don’t skip my
Breakfast
dinner
Lunch
8. I eat out
Once a month
Once a fortnight
Twice a week
Once a week
3-4 times a week
9. I observe fast. Yes/no. If yes, how often?
11. I dislike: Fruits: __, Vegetables: __, Other: __
12. Strong urges for any type of food and time: __
13. I am allergic to any food. Yes or No. (If yes then, please specify below)
14. I consume alcohol or do not. (If yes then please specify the quantity and frequency)
15. A-I Like /Dislike exercises. Type of exercises I do/prefer are
21. Family history of
Obesity
High Blood Pressure
Diabetes
Low Blood Pressure
Hypertension
Thyroid
Name of family Physician:
Mobile No
22. Submit your Recent blood tests reports on niruddha.yog@hotmail.com
Signature
Date
Place
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