QUESTIONNAIRE \6 YEAR BOY VORGUT MN esteem ae. é on ome GENERAL DETAILS e Name — paeuno auatia ¢ D.O.B.— 22 |o08\2008 e Gender — mace e Phone no. — 9321408925 e Alternate phone no. — - ¢ Email address — om enbhotia 2003 @qmail.com e Residential address —102 Sownneam pret BHAN FO e Ethnic background — Punjab yat> SOTAT ANTHROPOMETRIC MEASUREMENTS e Height— 5's" A124 Um e Weight— 54 e B.MI.— 18-6 yl" 0 1L.B.W.-— 62.'% ¢ B.M.I. Classification — Undmodgnt e ENEROY — 2500-3000 Keel (Cerda) ° PROTEIN — SS - 60 qm Cana)'¢ No. Of earning members — | ¢ Marital status — Un mouied e If married then no. Of children and their age e lf married then spouse's occupation — - e Mode of commutation-— ~- ACTIVITY PROFILE e Any physical activity — Yes Timing of activity— s?m \- 2 how ¢ Do you go for a walk , if yes then at what time — vo e During exercise, do you sweat more or less? — Les e Sleep hours— 1 - 8 hows e Lying down hours— — e What do you prefer stair or elevator? — stain ¢ Do you walk small distances? — YesICATION gree— SSC DICAL HISTORY ¢ Personal history of obesity? — 9 ¢ Personal history of diseases? — throat Iofecton, lous! e Suffering from any disease? — - e If yes then which and medication for disease — - e Any surgery/operation- — e Any specific food allergy — ssence e Heredity if any? — - DIETARY PATTERN e No. Of meals per day— 4 -*> e Vegetarian OR Non-vegetarian — e If vegetarian, then do you consume eggs? — Yu e If non-vegetarian, then frequency of non-veg per week— — e Frequency of following per day :Wvater— 5-6 gasses \-2 Dried fruits — - ~ e Amount of sugar added in tea/coffee/milk — 2 1° e Do you add table salt— Yu e Frequency of following per week : Fried— \ Farsan— 7 Packaged food— Soft drink-— o Sweets— 2 Chaat— 5 Fast food- “4 ¢ Which cooking oil is used? — Upiound nat , Mustard , Soyabeor e Time taken to finish 1 bottle of oil? — 3 webs ¢ Do you consume ghee? — 4 Time taken to finish 1 packet of ghee? — | w=" e Likes — fot food. Goh wee, pond , chook, cake ac Sao nS re e Dislikes — mr god | Prlueds , dobiya gholle, i gp.u get stressed easily? — ”° Do you cry often? — 1% Are you satisfied with your life right now? — 4u e Are you short tempered? — Yu ¢ Do you get worried easily? — No e Do you overthink? — wo ¢ Does your mood affect your diet? - 0 e Heavy sleeper OR light sleeper — Heavy 24-HOUR DIETARY RECALL ra Menu Ingredie Amt Energy Protein gents (kel) ae ron ‘bean Lunon 2 (oad) a eee a ou. ou pet toon Born i Osea 490 mL 200 10: Ain tb, puta qual su ae lott tae four. a | Phack gam oa = glu atoo of te ic Sean a00 botte dound 100 qm 30 r sa 10g 40 Bod Time Mk Worm ok Soom _2 09 Bon vto sagan \Sqm 60 ug Kol DIET CHARTae \ Crna) lo am eee ; 7 309m 97 Beet oh Pet er © OW al Pon ata Potato at \oS qm. ath | Crchat Banana. , mango 100 = 2009» tohdle haat flo 20 Ym s30PM RoW 4 gg abe yrony (oo ym Bie Ate 30 4m Oak an 30 Grn rae Cor = nb Ue m9*- Butomik + dt \qhee = 159m [50 me et. Saloal benkmoot , tornado, 104m Cacurioty Onto duld, Rouoal C2) + L104 mr 4104 n Beer sans | 5° ie = a n \ ; Sidexk otal 04m ar oe 30 - Wagm — mao. ae ee 309m 4504 a Oe moma bhi 30 Gr ee s Tieatts oy 129-299 q Rem | me or | Sox Cadd usm { On mtb) aes 909 "M Pou hott bread ange Minn oh fear | uogm | Dhos0 |DAli) = Sobor dad . Bo- Loqm eee - of ee Dal eg del Pastor Pol Sabet | Cn alla 4 t Solo2i 2 oi jae |fo opt od Tmt | mile ; | midk Ea ai 10 gm ZE | Tham oie TIP: » Bacsuae autty hour to 2 \ dow © Ancooode tor a! veyatobles (pid 22! grain Sm wo Oe mals © UncHAauk ‘s prokin Pole 5 cashohydrol Pntake ao Gmounk wn cad, mack puord poutaged [od fost ‘ool » jure (ee Bae, 4 ot vith aa) , dvoid mobile plone ey, | {howe , ses Suds, Soun| on orl pushur — Of tand- 4 dinno. @ dncuay ith Mtoe 2 Gak tm bigger Mod plots , gloves ) bocsls, - prod Saft dsints, Soda ; feo, (alee