Welcome to Dr.Janani's Health Management Center

Monday − Saturday : 10:00AM − 7:00PM

+91 - 78456 51734

djhmc2016@gmail.com

Questionnaires - I

Medical History

1. Are you suffering from any of the following medical conditions?

Obesity

Diabetes

Hypertension (High blood pressure)

Dyslipidemia (cholesterol)

Arthritis

Hormonal disorder

Respiratory disorders

Hypothyroidism

None

Other

2. Do you have a family history of one or more of the following health disorders? Please tick all that apply?

Obesity

Hypertension(High blood pressure)

Dyslipidemia

Diabetes

Asthma

Arthritis

Stroke

Cancer

None

Other

3. Do you experience any of the following symptoms often?

Acidity

Gases

Bloating

Constipation

None

Others

4. Do you have any eyesight related issues/illness?

Yes

May be

Other

5. Are you taking any prescribed medication? If yes, kindly specify the health condition and medication with dosage?

6. Are you allergic to any medication? If yes please specify details.

7. Have you undergone any surgery? If yes please specify.

8. Have you ever been hospitalized? If yes, please specify the health condition and duration.

9. For females – Is your menstrual cycle regular?

Yes

Other

Personal Details

1. Do you smoke? If yes, specify number of cigarettes you smoke in a day.

> 31

21 - 30

11 - 20

3 - 10

< 2

Other

2. Are you in habit of chewing tobacco or paan?

Yes, regularly

Yes, occasionaly

Other

3. How much alcohol do you consume in a week?

Daily

Thrice

Once or twice

Don’t drink

Other

4. How often do you feel stressed?

Always

Often

Sometimes (under specific circumstances)

Rarely

Never

Other

5. On an average how many hours do you sleep at night?

< 4hrs

4 - 5hrs

6 - 8hrs

> 8hrs

Other

Food Habits

1. Which of the following best describes your food pattern?

Vegetarian (plant, foods, dairy products)

Ova vegetarian (plant foods, dairy products, eggs)

Non-vegetarian(plant foods, dairy products, eggs, meat, fish, chicken)

Jain

Vegan

Other

2. Do you feel any discomfort after eating certain foods?

Bread , pasta, pizza

Dairy, cakes, pastries

Spicy Food

Sea Food

Meat

None

Other

3. Please tick if you crave for certain foods during the day?

Sweet

Salty

Bitter

Sour

Savory

4. What is your intake in a day (mention in litres)?

5. Do you eat when you feel stressed unhappy angry or bored?

Yes

Other

6. How often do you consume these foods?

	Everyday	1 - 2 times a week	3 - 4 times a week	Once in a month
Fruits & vegetables
Milk & milk products
Green tea
Processed ready to eat foods (noodles, pasta)
Fried snacks (chips, samosa)
Fast foods (pizza, burger)
Salt preserved foods (pickle, sauce, ketchup)
Soft drinks

7. Do you skip any of your meals? if yes kindly specify which meal:

	No	Yes, Sometimes	Yes Always
Break Fast
Lunch
Dinner

8. Are you allergic /intolerant towards any one or more or more of the following foods?

Milk and milk products

Eggs

Nuts (like peanuts)

Sea foods

None

Other

9. How frequently do you dine or order food from a restaurant/hotel?

Every day

3 to 4 days a week

Once or twice a week

Fortnightly

Once a month

Never

Other

10. Do you take any external vitamin or mineral supplementation? If yes, please Specify?

Physical Activity

1. What physical activity do you undertake?(you can select multiple options)

Sports (please specify the type of sport
in the other column)

Running

Weight Training

Cycling

Other

2. How many hours do you work out daily?

< 0.5h

0.5 - 1hr

1 - 2 hr

> 2h

Other

3. How frequently do you exercise/indulge in physical activity?

1 - 2 times / week

3 - 4 times / week

5 - 6 times / week

7 times / week

Other

4. How long have you been indulging in some form of physical activity?

< 1 month

1 - 3 month

3 - 6 month

6 - 12 months

> 1 year

Other

5. What is your fitness goal?

Fat loss

Long distance running

Professional sports

Muscle building

General health and well being

Other

6. What are you current activity levels?

Sedentary ( Little or No Exercise)

Lightly Active( light exercise 1-3 days/ week)

Moderately active (moderate exercise 3-5 days / week)

Very active (hard exercise 6-7 days / week)

Highly active (very hard exercise and a physical job)

Other

7. Are you availing (or have availed in the past) the services of an exercise physiologist / personal trainer / sports coach / performance enhancement specialist to improve your performance?

Yes

Other

8. Have you ever suffered from a sports/ exercise related injury? It yes, what was the nature and severity of your injury?

9. What supplements do you take (if any) to improve your performance during workout/playing sports?

How to reach us

Paramathi : 32/5, Dr. Janani’s Health Management Center, Main Road, Paramathi PO., Paramathivelur Tk., Namakkal - 637 207.

Salem : 29, Dr. Janani’s Health Management Center, 1st Floor, Brindavan Road, Near Balaji Temple, Fairlands, Salem, Tamil Nadu - 636 016.

+91 78456 51734

djhmc2016@gmail.com

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