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General Information
Name
Email
Gender
Male
Female
Other
Age (Years)
NIC
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Physical Activity Level
Occupation
Do you engage in any exercise? eg: Brisk walk, jogging, swimming, gym etc
Yes
No
If yes, how many hours per day/per week?
How many hours do you sleep per day?
Ethnicity Language Preference
English
Sinhala
Physical Conditions
Pregnancy
Breast Feeding
Disability to Walk
Bed Ridden
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Anthropometric Data
Height (m)
Weight (kg)
Hip Circumference (cm)
Waist Circumference (cm)
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Bio Medical Data
Parameter
Value
RBS
FBS
HbA1C
Blood Pressure
LDL
HDL
Total Cholesterol
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Medical History
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Dietary History
24-Hour Recall
Date
Time
Meal
Food Item and Quantity
Bed Tea
Breakfast
Snack 01
Lunch
Snack 02
Dinner
Snack 03
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Other Information
Please mention if you have any food allergies
Do you avoid any food? Please mention
Do you want any dietary advices from our dietitians/nutritionists?
Yes
No
Please write if you have any special requests from us
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