“`html Personalized Diet Assessment | RG Wellness Clinic

Personalized Diet Assessment

RG Wellness Clinic

Complete this assessment to help us develop an individualized, goal-based nutrition plan.

1. Patient Information

Patient Name *

Preferred Name

Age *

Sex *

Mobile Number *

City / Location

Occupation

Typical Work Pattern

Mostly sitting / desk job Mostly standing Physically active Shift work

2. Primary Health & Nutrition Goals

Please select your main objectives. These will help determine the structure and priorities of the diet plan.

Weight loss Healthy weight gain Fat loss / body composition Muscle / strength support Blood glucose management Prediabetes management Blood pressure management Cholesterol management PCOS-related nutrition support Thyroid-related nutrition support Digestive health Improve energy Support better sleep Fitness / sports nutrition Improve overall eating habits Other

What is your most important goal?

Why is this goal important to you?

Desired timeframe

What would make you feel that the plan is successful?

3. Body Measurements & Weight History

Current Weight (kg)

Height (cm)

Waist Circumference (cm)

Hip Circumference (cm)

Neck Circumference (cm)

Usual Weight (kg)

Highest Adult Weight (kg)

Lowest Adult Weight (kg)

Recent Weight Change

Approximate change in last 3–6 months

Previous weight-loss / diet attempts

4. Medical & Health History

Please mention diagnosed medical conditions and relevant health concerns. Do not stop or change prescribed medication based on this form.

Diabetes Prediabetes Hypertension High cholesterol / triglycerides Thyroid disorder PCOS Kidney disease Liver disease / fatty liver Heart disease Gastrointestinal condition Anemia / iron deficiency Vitamin/mineral deficiency Gout / high uric acid Food allergy Other

Current medical diagnosis / concerns

Previous surgeries / hospitalizations

Family history

Any current symptoms or health concerns?

5. Medications, Supplements & Allergies

Current Medications

Vitamins / Minerals / Supplements / Herbal Products

Known Food Allergies

Food Intolerances

Foods that cause symptoms

6. Recent Laboratory / Investigation Information

Enter recent values if available. Mention date where possible.

Fasting Glucose

HbA1c

Post-meal Glucose

Total Cholesterol

LDL

HDL

Triglycerides

TSH

Vitamin D

Vitamin B12

Hemoglobin

Creatinine / eGFR

Uric Acid

ALT / AST

Other Important Results

Upload / report details

7. Current Dietary Pattern

Diet Type

Typical Number of Meals / Day

Breakfast Timing

Lunch Timing

Dinner Timing

Typical Bedtime Snack?

Describe your usual breakfast

Describe your usual mid-morning intake

Describe your usual lunch

Describe your usual evening snack

Describe your usual dinner

Other foods / beverages consumed regularly

8. Food Preferences & Restrictions

Favorite Foods

Foods You Dislike

Foods You Absolutely Do Not Want in the Plan

Foods You Prefer to Include

Preferred Cuisine

Spice Preference

Tea / Coffee Preference

Sweets / Dessert Preference

9. Eating Behaviour & Food Relationship

I eat very quickly I frequently eat late I eat more when stressed/emotional I eat when bored I experience strong food cravings I eat at night I frequently skip meals I snack frequently I eat while watching TV/mobile I frequently eat outside

Most common cravings

When do cravings usually occur?

What usually triggers overeating?

What makes it difficult to follow a diet?

10. Hydration & Beverages

Approximate Water Intake / Day

Tea / Day

Coffee / Day

Soft Drinks / Week

Packaged Juice / Week

Other Sweetened Beverages

11. Physical Activity & Exercise

Overall Activity Level

Average Daily Steps

Exercise Type

Exercise Frequency / Week

Average Exercise Duration

Preferred Exercise Time

Physical limitations, pain or injuries affecting activity

12. Sleep & Recovery

Usual Bedtime

Usual Wake Time

Average Sleep Duration

Sleep Quality

Night awakenings

Daytime fatigue?

13. Digestive & Gastrointestinal Assessment

Bloating Excess gas Acidity / heartburn Constipation Loose stools Abdominal discomfort Nausea Feeling full quickly

Bowel movement frequency

Any known digestive diagnosis?

Describe digestive symptoms and food triggers

14. Women’s Health — If Applicable

Menstrual Cycle Pattern

Cycle Length

PCOS / PCOD diagnosed?

Pregnancy status

Other relevant women’s health information

15. Food Preparation & Home Environment

Who usually prepares your meals?

Cooking facility available?

Time available for cooking

Typical monthly food budget

Do you eat with family?

Access to fresh vegetables/fruits

Family/social factors that may affect your diet

16. Eating Outside, Travel & Special Situations

How often do you eat outside?

Where do you usually eat?

How often do you travel for work/personal reasons?

Common travel food challenges

Special occasions / festivals / social eating challenges

17. Typical Daily Routine

Wake-up time

Work start time

Work end time

Commute duration

Family responsibilities

Typical stress level

Describe your usual weekday routine

Describe your usual weekend routine

18. Diet Adherence & Personalization

How confident are you about following a structured plan?

Preferred level of diet structure

Preferred number of food options per meal

Do you prefer exact portions?

What would make this diet plan easier for you to follow?

What should we avoid making the plan feel unrealistic?

19. Detailed 24-Hour Food Recall

Please describe everything consumed yesterday, including approximate quantities, beverages, snacks, tasting while cooking and late-night intake.

On waking

Breakfast

Mid-morning

Lunch

Evening

Dinner

Late-night / bedtime

Anything else consumed?

20. Final Patient Priorities

What is the ONE biggest change you want this diet plan to help you achieve?

What are your biggest concerns about starting a diet plan?

Anything else you want your nutrition professional/doctor to know?

21. Confirmation

I confirm that the information provided above is accurate to the best of my knowledge. *

I understand that an individualized diet plan may need to be modified according to medical conditions, medications, laboratory results, progress and clinical advice. *

I agree to be contacted regarding my diet assessment and nutrition plan.

Please review your information before submitting.

“`