Registration
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Personal Details
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Mr.
Mrs.
Miss.
Ms.
Title
First Name
Last Name
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Male
Female
Gender
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Single
Married
Un Married
Divorced
Marital Status
Age
DOB
Height in Cm
Weight in Kg
Contact Details
Phone / Mobile No
Email Id
City
State
Country
Postal code
Address
Food Habits
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Yes
No
Alergic to any Food?
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Vegetarian
Non-Vegetarian
Food Preferenced
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South Indian
North Indian
Jain
Others
Preferred Cuisines
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No
Daily
Occationally
Do you take Outside Food?
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Yes
No
Do you Smoke?
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Yes
No
Do you consume alcohol?
Other Food Habits
Medical Details
Blood Group
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Yes
No
Alergic to any Medicine?
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No
Diabetes
Blood Pressure
Heart Problem
Obesity
Others
Family members History?
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No
Acidity
Acid reflux
Acne (skin)
Acute renal failure
Anemia
Anorexia
Anxiety
Arthritis
Asthma
Bipolar disorder
Bloating
Bulimia
Cardio vascular diseases
Cervical Spondylosis
cholelithiasis
Chronic diarrhoea
Chronic hepatitis
Chronic kidney diseases
Colitis
Conception (natural)
Congestive heart failure
Costipation
COPD
Covid 19
Coronary Artery diseases
Crohn's Disease
Cravings for food
Depression
Diabetes
Digestive disorder
Diverticulitis
Dyslipidemia
Dysmenorrhoea
Epilepsy
Erectile dysfunction
Fatique
Fatty liver
Fibroid
Gluten insesitivity
Infertility
Insomnia (lack of sleep)
Irregular menses
Joint pain
Kidney stones
Kidney diseases
Kidney transplant
Liver disorder
Leg cramps
Liver problems
Low immunity
Low vitamin B12
Low vitamin D
Menopause
Mental issues
Migraine
Mitral valve replacement
Obesity
Osteoporosis
Overweight
Pain management
Pancreatitis
Parkinson's disease
Pre puberty
PMS
Pulmonary embolism
Recurrent cold and cough
Recurrent uti
Recurrent kidney stones
Rheumatoid arthritis
Sinusitis
Stroke
Thalassemia
Ulcerative colitis
Umblical hernia
Underweight
Others
Are you Suffering from any of these?
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Yes
No
Other Medical History?
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