VNP Questionnaire Link New I

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General Terms and Conditions

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Access to VNP Counsellors:

Access to VNP Counsellors ("Counsellors") will be available only based on the package chosen. They will also get access to email support with an estimated response time of 24-48 hours unless there's an emergency. Please note that WhatsApp support is accessible only between 10 am to 7 pm IST and any message sent outside these timings will be responded to only on the next day. Please note that access to counsellors will be available only from Monday to Friday. They will not be reachable on Sundays unless in case of emergencies.

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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 of these environmental allergens? *

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

Current Lifestyle Information - Monthly Cycles

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 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