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Client Inquiry Form
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Gender
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Male
Female
Trans
Others
Work Type
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Sedentary
Moderate
Heavy
Physical Activity
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Yoga
Walking
GYM
Sports
Cycling
Swiming
Running
Calisthenics
Zumba
Others
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Alcohol Consumption
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Yes
No
Occassionally
Smoking/Tobacco
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Yes
No
Sometimes
Occassionally Only
What is your Primary Health Goal?
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Weight Loss
Muscle Gain
Diabetes Reverse
PCOD Reverse
Thyroid Reverse
Cardiovascular Disease Management
Liver Detox
Others
What is your target timeline for achieving this goal?
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Do you have any diagnosed medical conditions?
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Thyroid
Diabetes
Hypertension
PCOD
Fatty Liver
Arthritis
Do you have recent blood tests reports ?
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Yes
No
Do you experience symptoms like bloating, acidity, gas, constipation, or loose stools?
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Yes
No
How often do you pass stools daily, and what is the consistency like?
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How many hours of sleep do you get on average per night?
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Do you have trouble falling or staying asleep?
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What is your current stress level ?
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Low
Moderate
High
Any recent emotional stress or life changes?
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How is your overall energy throughout the day?
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Do you experience frequent fatigue or brain fog?
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Yes
No
Sometimes
Feels Like
Don't Know
Do you have any specific food cravings (e.g., sugar, salty, caffeine, etc.)?
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Are you vegetarian, vegan, or non-vegetarian?
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Any food intolerances, allergies, or dislikes?
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How many meals and snacks do you usually have in a day?
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What does your daily routine look like ?
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Do you have access to a kitchen or cook for yourself?
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Is your menstrual cycle regular?
Any history of PCOS, endometriosis, hormonal imbalances?
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Do you prefer home-cooked meals or are open to packaged/supplement-based options?
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Are there any cultural or religious dietary restrictions to consider?
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What does your current daily diet look like? (1-day recall with meal timings and portion sizes)
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Any Specific Date & Time to call you ?
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