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Name Accomodation Sex D.O.B Marital status Blood group Family income Do you have any chronic illness?

Food preferences Are you Vegetarian/Non-vegeterian/Eggterian? How many No. of meals do you haveday Do you have breakfast? Milk and milk products Which Milk do you have daily, cow/buffalo toned/full cream? Buttermilk/ curd Butter Ghee Milkshakes Icecream Cheese Paneer Fruits fresh/packaged/canned Dry fruits and nuts Salads and sprouts Green leafy vegetables Others If non-veg, poultry/sea foods/ red meat? Fast food : chips, burgers, pizzas, samosa vada pav, chaat, instant noodles, instantmeals Bakery and confectionary products: biscuits, khari, cakes, pasteries, namkeen, rolls Sweets : chocolates, khoya based sweets, white sugar, home made sweets Frequency of outside food Beverages: tea green/black/milky, coffee, soft drinks, alcoholic drinks

University Of Pune Interdisciplinary School of Health Science 1. Personal Information Name D.O.B Sex Blood group Marital Status Accommdation Address Monthly family Inc ome(INR) Below 1000 0 10000-30000 30000-50000 Above 50000

2. Food preferences Vegetarian Non Vegetarian Eggetarian No of meals in a day Breakfast Lunch Dinner Others, specify 3. Type of food consumed: S.| Food Group N 1 Dairy products Y/ N Food Items Milk Cow milk Buffalo milk Curd Buttermilk Butter Ghee Cheese Paneer Milkshakes Ice-cream 2 Fruits Homemade/Fresh Packaged/ Canned Frequency


Green Leafy Vegetables Non-vegetarian food Poultry Sea-food Red meat

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Salads, sprouts Dry fruits/nuts Groundnuts Cashewnuts Almonds Walnuts Dates Raisins, dry fig s

Indian snacks (Most frequently consumed) Fast food Burgers/Pizzas Vada-pav/sam osa/ Instant Noodle s Instant Meals ( Ready to Eat)

Bakery & Confectioneries Sweets

Biscuit/Khari/P astry/ Rolls White sugar Chocolates Khoya based s weets Home-made s weets

10 Beverages

Tea Coffee Aerated drinks Alcohol

11 Outside food