ONP Questionnaire Link Archives - Varsha Nutrition Protocol

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Name *

First

Last

Date *

Email *

Date Of Birth *

Gender *

Male
Female
Other

Address *

Phone Number *

Height *

Weight *

Neck Circumference *

Waist Circumference *

Hip Circumference *

Relationship Status *

Single
In a relationship
Married
Widow/Widower

Apart from wholistic wellness what are you other priorities/goals? *

I want to lose fat / weight
I want to gain muscle / weight
I want to reverse my current medical condition

Current Conditions

Are you allergic to any medications? *

Yes
No

History of past illnesses, surgeries or injuries if any. *

For ex., Heart Attack (2 Years back)

Have you been regular with vaccine boosters? *

Yes
No

Are you on any medications currently? *

Yes
No

Current Lifestyle Information - Work

What is your current occupation? *

Current Lifestyle Information - Habits

Do you smoke? *

Yes
Yes, socially
No
No, but I used to in the past

Do you consume alcohol? *

Yes
No
No, but I used to in the past

Do you drink caffeinated beverages? *

Yes
No

Do you consume any form of drugs for recreational purposes? *

Yes
No
No, but I used to in the past

Current Lifestyle Information - Sleep

Do you have trouble falling asleep at night? *

Always
Sometimes
Never

Do you take any medication(s) before bed? *

Yes
No

Current Lifestyle Information - Exercise

How regularly do you exercise? *

Always
Sometimes
Never

Current Lifestyle Information - Nutrition

On average, how many litres of water do you consume daily? *

Less than 2 litres
2-4 litres
More than 4 litres

Do you consciously avoid the consumption of any food products for personal reasons? *

Yes
No

Do you face discomfort when consuming certain food items? *

Yes
No

Do you face bowel problems when you consume any food items? *

Yes
No

Are you willing to take whey protein supplement? *

Yes
No

How would you describe your bowel movements? *

Normal
Constipated
Diarrhoea
Alternating between constipation and Diarrhoea

Do you experience pain before/during/after your bowel movements? *

Yes
No

How often do you resort to de-worming? *

Never
Once in 6 months
Once in a year
Not unless the doctor advises it

Relationship

Your typical meal consumption

Please list down what you would typically consume on a normal day.

Breakfast *

Mid Day Snack *

Lunch *

Evening Snack *

Dinner *

Meal Preferences

How would you prefer your meal composition to be? *

More of Carbohydrates
More of Fats

How would you like to approach your meal plan? *

Weigh your food (using a food scale)
Weigh your food ( without using a food scale )

Would you like snack options along with your protocol? *

Yes
No

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