Nutri Diet Clinic Nutrition · Well Being · Lifestyle

Patient Intake Form

Guided by Dt. Afreen Sultana, Certified Clinical Dietician & Nutritionist.

Privacy notice

This detailed intake helps Dt. Afreen Sultana understand your full picture and prepare a safe, personalized diet plan. We collect:

Purpose. This information is used solely by Dt. Afreen Sultana to review your case and prepare a personalized diet plan. It is transmitted over an encrypted connection and stored securely.

1. Before We Start
Who are you filling this in for?
Please tell us who this plan is for.
Which language should we write the plan in?
Please choose a language for the plan.
Would you like a simple, visual plan? (optional)
2. About You
Full name is required.
Age must be a whole number between 1 and 120.
Sex (for clinical purposes)
Please select an option.
Enter a valid mobile number.
Enter a valid email address.
Occupation is required.
For example, spouse, children, parents.
3. Height and Weight
Enter feet between 3 and 7.
Enter inches between 0 and 11.
Height in cm must be between 90 and 220.
Weight must be between 20 and 250 kg.
Has your weight changed in the last 6 months?
Please select an option.
Waist measurement unit
Hip measurement unit
4. Health History
Have you been diagnosed with any of these?
Choose "None of these" if none apply.
Select at least one, or choose "None of these".
Have you ever had any surgery?
Please select an option.
Any of these in your close family? (optional)
5. Doctors
Which specialists are you seeing? (optional)
May we share your plan with your doctor?
Please select an option.
6. Medications
Add one or more clear photos of the strips or boxes.
Please add at least one photo of your current medicines.
Which over-the-counter products do you use?
Choose "Nothing" if none apply.
Select at least one, or choose "Nothing".
7. Blood Reports
You can add more than one file.
When was your last blood test? (optional)
8. Safety
Have you had any of these recently?
Choose "None of these" if none apply.
Select at least one, or choose "None of these".
Do you have any food allergy?
Please select an option.
Any foods that cause you discomfort? (optional)
9. What You Eat
What best describes your diet?
Please select an option.
Which non-vegetarian foods do you eat? (optional)
This field is required (write "None" if there are none).
<span id="diet.yesterdayFoodRecall-remaining" data-max="2000">2000</span> characters remaining
Please tell us what you ate yesterday.
Was yesterday a typical day of eating? (optional)
How many meals do you eat per day?
Please select an option.
Which meal do you skip most often? (optional)
How many days a week do you eat outside food?
Please select an option.
This field is required (write "None" if there are none).
10. Food Frequency
Food groupNever1-2/wk3-5/wkDaily
Fruit
Vegetables
Green leafy vegetables
Dal or legumes
Milk, curd or paneer
Nuts or seeds
Millets
Fried food or namkeen
Sweets or mithai
Biscuits or bakery items
Soft drinks or packaged juice
Pickle or papad
Pick one column for every row.
11. Kitchen Measures
Enter the litres of oil used per month.
Enter the number of people.
Which oils or fats do you cook with? (optional)
Do you add raw salt at the table? (optional)
Please tell us how many rotis per meal.
How much rice do you eat per meal?
Please select an option.
What size katori do you use as a reference?
Please select an option.
12. Daily Clock
Please enter your wake time.
This field is required.
This field is required.
Please enter your sleep time.
Gap between your last food and sleep (optional)
Enter the number of cups per day.
How much water do you drink per day?
Please select an option.
Where do you usually eat your meals? (optional)
How long does a typical meal take? (optional)
How often do you eat after 10 pm? (optional)
13. Digestion
How often do you pass stool?
Please select an option.
Which best describes your stool?
Please select an option.
Do you strain when passing stool? (optional)
Do you get any of these digestive symptoms?
Choose "None of these" if none apply.
Select at least one, or choose "None of these".
When is acidity worst for you? (optional)
Any difficulty chewing or swallowing?
Choose "No difficulty" if none apply.
Select at least one, or choose "No difficulty".
14. Women's Health

You can skip this whole section if it does not apply to you. Only the pregnancy status question is required (it includes a "Doesn't apply" option).

Are your periods regular? (optional)
How would you describe your flow? (optional)
Do your periods last more than 7 days? (optional)
Any contraception or hormonal treatments? (optional)
Are you pregnant, trying, or breastfeeding?
Please select an option.
Any recent change in hair fall? (optional)
15. Sleep, Activity and Stress
Enter your sleep hours (between 2 and 14).
How is your sleep quality? (optional)
Do you snore? (optional)
How active is your typical day?
Please select an option.
This field is required (write "None" if you do not exercise).
What gets in the way of being active? (optional)
Your stress level (1 = low, 5 = high) (optional)
How often do you eat due to stress or emotion? (optional)
Do you use any of these? (optional)
16. Kitchen and Day
Who prepares your meals?
Please select an option.
Who buys the groceries? (optional)
How much time do you have to cook?
Please select an option.
Do you carry a tiffin?
Please select an option.
Do you get a proper meal break at work? (optional)
What is your food budget preference? (optional)
Any kitchen equipment or storage limits? (optional)
How often do you travel? (optional)
17. Goals
What would you like to achieve?
Please choose at least one goal.
This field is required.
How ready are you to make changes? (1 = not ready, 10 = very ready)
Please pick a number from 1 to 10.
What might get in the way? (optional)
How would you like us to follow up? (optional)
This field is required (write "None" if there is nothing else).
18. Consent
Please confirm the information is accurate.
Please confirm you understand this is not a replacement for medical care.
Please consent to your information being stored.
Please type your name to sign.
Please enter the date.