Patient Assessment Form

1. Personal & Contact Information

Full Name *

Age *

Gender *

Date *

Occupation

Address

Contact Number *

Email ID

2. Medical History

Known Medical Conditions (e.g., Diabetes, Thyroid, PCOD, Hypertension)

Current Medications/Supplements

Past Surgeries/Hospitalizations

Family Medical History

Any Allergies/Intolerances (Food or Medicine)

3. Dietary Pattern

Dietary Preference *

Vegetarian Non-Vegetarian Vegan Eggetarian

Describe Your Daily Meals (Breakfast, Lunch, Dinner, Snacks)

How Often Do You Eat Outside or Order Food?

Do You Skip Meals? If Yes, Which One(s)?

Any Food Cravings or Aversions?

Do You Eat More During Stress or Emotions?

How Much Water Do You Drink Daily? (in liters or glasses)

Do You Consume Tea/Coffee/Soft Drinks Regularly?

4. Lifestyle & Physical Activity

Describe Your Typical Daily Routine

Physical Activity Type, Frequency & Duration

Hours of Sitting Per Day

Sleep Duration & Quality

Stress Level (1-10)

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How Do You Manage Stress?

Do You Practice Yoga/Meditation? If Yes, How Often?

5. Disease-Specific Questions

For Thyroid: Energy Levels, Cold Sensitivity, Hair Fall, Weight Changes

For Diabetes: Fasting/Postprandial Sugar, Frequency of Urination, Thirst, Appetite

For Obesity: Weight Gain Pattern, Snoring, Cravings, Emotional Eating

For PCOD/PCOS: Menstrual Cycle Details, Acne, Hair Growth, Mood Swings

For Hypertension/Heart: BP Readings, Chest Pain, Salt Intake, Family History

6. Emotional & Mental Health

Do You Experience Anxiety, Irritability, or Low Mood?

Do You Eat Due to Boredom, Sadness, or Stress?

How Do You Relax or Unwind?

How Satisfied Are You With Your Body Image? (1-10)

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7. Health Goals & Motivation

What Are Your Primary Health Goals?

How Much Weight Do You Want to Lose/Gain and By When?

What Motivates You to Make This Change?

Have You Tried Any Diet Plans Before? What Worked and What Didn't?

How Committed Are You to Follow the Plan? (1-10)

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Nutrition & Wellness Clinic

by Dr. Sujata Panda