Zi Clinic Questionnaire - Optimal Nutrition Protocol

Name *

First

Last

Email *

Date Of Birth *

Gender *

Height *

Weight *

Neck Circumference *

Waist Circumference *

Hip Circumference *

Apart from holistic wellness, what are your other priorities/goals? *

What may be some of the health issues you are currently facing? *

What may be some of the health issues you have faced in the past? *

What is your current occupation? *

How many hours a day do you work? *

Less than 8 hours
8 hours
9 hours
More than 10 hours

How many hours a day do you spend in the sitting (chair) position? *

Less than 3 hours a day
3-5 hours a day
6-8 hours a day
More than 8 hours a day

Do you work the night shift? *

Yes
No
Rotational Night Shift

Do you smoke? *

If yes, how often do you smoke in a day? *

Do you consume alcohol? *

How often do you consume alcohol? *

On average, how many hours do you sleep at night? *

At what time do you usually sleep? *

What prevents you from falling asleep/having a sound sleep? *

I cannot fall asleep when there is any light source around
I work late into the night
I usually over think in bed
I use gadgets late into the night(Laptop, Phone, etc.,)
Other

If Others, Please Specify

How regularly do you exercise? *

Always
Sometimes
Never

What are some of the physical activities you do? *

How many minutes in a day do you engage in your preferred physical activities? *

Are you allergic to any of the following food items? (Confirmed or Suspected by you) *

Which of the following food lifestyles do you follow? *

Do you follow any of the following dietary patterns? *

Would you like Intermittent Fasting(IF) to be enrolled in your diet? *

Yes
No
Need to consult

How many times a day do you have/try to have a balanced meal? *

Once
Twice
Thrice

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

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

Do you consume junk food? *

Yes
No

If yes, please choose which *

Fast foods
Packaged foods
Canned foods

Do you usually eat until you are uncomfortably full? *

Always
Sometimes
Never

Do you feel hungry within 3 hours of having eaten a meal? *

Always
Sometimes
Never

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

Yes
No

If yes, what? *

Do you face discomfort when consuming certain food items? *

Yes
No

If yes, what? *

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

Yes
No

If yes, what? *

Are you currently taking whey protein supplement? *

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

Have you been pregnant before? *

Yes
No

Was it a C-section or a Normal delivery? *

C-Section
Normal Delivery

Your typical meal consumption

Meal Preferences

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