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Dr. Richa Sharma
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ANTAH JAGRUTI
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Nature of food
Food items
Frequency
Quantity
Non-vegetarian
Red meat
White meat
Fish
Others
Smoking
Alcohol
Tobacco
Vegetarian
Milk
Tea/coffee
Ghee/oil
Curd/yogurt
Butter, cheese
Paneer
Dairy milk dessert
Full Name
*
Age
*
Sex
*
Select
Female
Male
Transgender
Religion
*
Education
*
Select
Under Graduate
Graduate
Post Graduate
Occupation
*
Select
Student
Private Job
Government Job
Business
Nature of work- day/night
*
Select
Day
Night
Not fixed
Marital Status
*
Select
Single
Married
No. Of Children
Address
*
Email I’d
*
Mobile Number
GENERAL EXAMINATION
B. P
*
Select
Normal
High
Low
Height
*
weight
*
Main Complaint
Any Surgery Undergone
*
Select
Yes
No
Any Regular medications
*
Select
Yes
No
Nature of Diet
*
Non-veg
Vegetarian
Mixed
Food Habit
*
Regular
Irregular
Other Habits
*
Smoking
Alcohol
Tobacco
No-Habit
Physical Activity
*
Active
Moderate
Sedentary
Mental Health
*
Positive view
Negative view