Name Email Phone Age Height (feet) Weight (Kgs) How would you describe your diet habits? Healthy / unhealthy How would u rate your level of stress? 1-10 1 2 3 4 5 6 7 8 9 10 How many hours of Screen time do you have? 0-3 3-5 5-8 8< How often do you exercise? atleast 5 times a week b) 3 times a week c) less than 2 times a week d) not regular in exercising Do you smoke Yes No ocassionally Do you consume alcohol ? Yes No Ocassionaly Have you undergone a surgery in the last 6 months? Yes No Do you have any of the following conditions? a) High Blood Pressure b) Heart condition c) Age > 50 c) None Do You currently have back Pain? Yes Yes but Mild pain No For what concern are you looking to find a solution? Diabetes Thyroidism Menstrual issues/ PCOS Infertility Breathing issues ( Asthma, Wheezing, COPD, Allergic Rhinitis) Migraine Cancer Cardiac Issues Weightloss General fitness and flexibility
