Full Name* Today's Date* -Month -DayYearDate Picker Icon Date of Birth* -Month -DayYearDate Picker Icon Age* Gender* FemaleMalePrefer not to say City* Country* I came to know of your program from* Referred by friendInternet SearchReferred by my healthcare providerOther Height (In inches or centimeters) Waist Circumference (In inches or centimeters) Height / Waist circumference. Waist circumference more than half of height is a rough measure of metabolic dysfunction. Current Weight Desired Weight Body Fat Percentage (If known) Birth Weight (If known) I was born by Normal Vaginal DeliveryCaesarean SectionForceps/ Vacuum ExtractionDon't know Family/Living Situation: Living with spouse/partnerLiving aloneLiving with extended family (parents,siblings etc) Children None1234More than 4 Do your children have any health challenge ? YesNo If yes, please describe Present Occupation Previous Occupation (if any) HISTORY Have you or your family recently experienced any major life changes? If so, please comment: How much time have you had to take off from work or school in the last year? 0 to 2 days3 to 14 daysMore than 15 days HEALTH CONCERNS What are your main health concerns? (Describe in detail, including the severity of the symptoms): When did you first experience these concerns? How have you dealt with these concerns in the past? DoctorsSelf-care Have you experienced any success with these approaches? If so, please explain: What other types of health practitioners or healers are you currently seeing? Have you undergone any surgical procedures? Please list with approximate dates. How often have you taken antibiotics in both your childhood and adult life Less than 5 timesMore than 5 times Please list any prescription medications you are currently taking Please list all vitamins, minerals, herbs and nutritional supplements you are now taking: NUTRITIONAL STATUS Eating Window My first food or drink intake of the day is at* 1 2 3 4 5 6 7 8 9 10 11 12 :Hour 00 10 20 30 40 50 Minutes AM PM AM/PM Option My last food or drink intake of the day is at* 1 2 3 4 5 6 7 8 9 10 11 12 :Hour 00 10 20 30 40 50 Minutes AM PM AM/PM Option Your relationship with food Do you have a healthy relationship with food? Have you been diagnosed with any of the conditions listed here? If yes, select the ones that apply.* NoDon't knowFood addictionAnorexia nervosaBinge eating disorderBulimia nervosaAvoidant or restrictive food intake disorderPicaRumination disorder Do you often eat when you are tired, bored, stressed or sad?* YesNo Do you find yourself eating large amounts of food in a short period of time, even when you feel uncomfortably full??* YesNo Do you feel guilty, ashamed, or distressed about your eating habits or food choices?* YesNo Do you use food as a reward or comfort, and do you feel a loss of control over your eating at these times?* YesNo Food Sensitivities Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom: (For example, wheat-bloating) Do you experience symptoms immediately after eating like bloating, gas, sneezing or hives? If you do, please explain: Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, If you do, please explain: Do you crave specific foods or drinks? If you do, please explain: Are you aware of any food allergies or sensitivities? If you are, please explain Please list the foods you eat regularly for meals and snacks Which of the following foods do you consume regularly? Soda/Cold DrinksRefined sugarFast foodDiet soda/Diet cold drinksDairy (milk, cheese, yogurt)AlcoholGluten (wheat, rye, barley)CoffeeTea Meals and snacks Breakfast Lunch Dinner Snacks Alcohol Intake Based on Canada’s Guidance on Alcohol and Health 2023 What is your risk?* No riskLow riskModerate riskIncreasingly high risk Do you now or have you in the past used or abused alcohol, drugs, prescription and non-prescription medications, tobacco or caffeine? Please explain: GUT STATUS Bowel Movement Frequency 1 to 3 times per dayMore than 3 times per dayNot regularly every day Bowel Movement Consistency* Type 1Type 2Type 3Type 4Type 5Type 6Type 7 Do you experience intestinal gas? If so, please explain: Is it excessive, occasional, odorous etc.? MEDICAL STATUS Please check any of the following conditions that may apply to you and your history. AllergiesAnaemiaAsthmaCancerHigh CholesterolDepressionDiabetesHigh Blood Pressure (Hypertension)Heart DiseaseHepatitisHead trauma with or without concussionKidney DiseaseThyroid DiseaseSexually Transmitted DiseaseStrokeChronic yeast infectionAny autoimmune diseaseOther Briefly describe your symptoms, chosen treatment(s), and dates of any of the conditions mentioned above Adverse Life Experiences Have you experienced any form of abuse (physical, emotional, or sexual) in your life?* YesNo Medical Symptoms Questionnaire In the sections below please score based on the point scale Point Scale 0 - Never or almost never have the symptom1 - Occasionally have it; the effect is not severe2 - Occasionally have it; the effect is severe3 - Frequently have it; the effect is not severe4 - Frequently have it, the effect is severe HEAD Headaches* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Faintness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Dizziness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Insomnia* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent EYES Watery or itchy eyes* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Swollen, reddened or sticky eyelids * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Bags or dark circles under eyes * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Blurred or tunnel vision* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent EARS Itchy ears* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Earaches, ear infections * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Drainage from ear * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Ringing in ears, hearing loss* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent NOSE Stuffy nose* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Sinus problems* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Hay fever* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Sneezing attacks* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Excessive mucus formation* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent MOUTH/THROAT Chronic coughing * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Gagging, frequent need to clear throat * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Sore throat, hoarseness, loss of voice* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Swollen or discolored tongue, gums, lips * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Canker sores* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent SKIN Acne* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Hives, rashes, dry skin* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Hair loss* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Flushing, hot flashes* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Excessive sweating* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent HEART Irregular or skipped heartbeat* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Rapid or pounding heartbeat* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Chest pain* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent LUNGS Chest congestion* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Asthma, bronchitis* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Shortness of breath* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Difficulty breathing* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent DIGESTIVE TRACT Nausea, vomiting * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Diarrhea* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Constipation* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Bloated feeling* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Belching, passing gas* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Heartburn* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Intestinal/stomach pain* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent JOINTS/MUSCLE Pain or aches in joints * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Arthritis* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Stiffness or limitation of movement * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Pain or aches in muscles * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Feeling of weakness or tiredness * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent WEIGHT Binge eating/drinking* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Craving certain foods * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Excessive weight* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Compulsive eating* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Water retention* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Underweight* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent ENERGY/ACTIVITY Fatigue, sluggishness * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Apathy, lethargy* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Hyperactivity* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Restlessness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent MIND Poor memory* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Confusion, poor comprehension * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Poor concentration* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Poor physical coordination * 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Difficulty in making decisions* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Stuttering or stammering* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Slurred speech* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Learning disabilities* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent EMOTIONS Mood swings* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Anxiety, fear, nervousness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Anger, irritability, aggressiveness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Depression* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent OTHER Frequent illness* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Frequent or urgent urination* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent Genital itch or discharge* 0 1 2 3 4 Never or almost never Frequent 0 is Never or almost never, 4 is Frequent TOTAL SCORE (Maximum of 284 points) 284 HEALTH HAZARDS Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)? YesNoMaybe If yes, please describe Do odours (smells) affect you? Please explain: Are you or have you been exposed to secondhand smoke? YesNo Do you have mercury amalgam dental fillings? YesNoMaybe LIFESTYLE HISTORY Wearable Device Do you use a wearable device like a smartwatch, Fitbit, Oura ring? YesNo If you use a wearable device, please name it. FitbitApple WatchOther SmartwatchOura RingOther device What insight did you get from using a wearable device? Exercise , Movement and Recreation Exercise Guidelines recommend that you should get 150-300 minutes of moderate-intensity physical activity or 75 to 150 minutes of vigorous-intensity physical activity every week. As a rough guide, when doing a moderate activity you should be able to talk with others without gasping for air. Do you exercise at moderate intensity for 150-300 minutes every week? YesNo Do you exercise at vigorous intensity for 75-150 minutes every week? YesNo What are your favourite physical activities? WalkingRunningBikingWeight TrainingHIIT (High-intensity Interval Training)GardeningYogaTai ChiDancingSwimmingGolfingTennisOther Daily Step Count What is your average daily step count? Less than 5000 steps5000 to 7500 steps7500 to 10,000 stepsMore than 10,000 stepsDon't measure Do you now or have you in the past used or abused alcohol, drugs, prescription and non-prescription medications, tobacco or caffeine? Please explain: Stress Management What are your stress management techniques? Spend time in natureMeditation/Relaxation Response/Mindfulness-based practiceApps like Headspace, Inner BalanceTai ChiYogaQigongOther Sleep Do you struggle falling asleep? Staying asleep? Struggle Falling AsleepStruggle Staying AsleepI do not struggle with either Do you wake up during the night? YesNo If yes, please describe How many hours do you sleep per night? Less than 6 hours6.5 to 8 hoursMore than 8 hours Do you have regular sleeping and waking up times during weekdays and weekends? YesNo.I do shift work If your answer to the question above is No, do you sleep-in during weekends to catch up on missed sleep? YesNo If you do shift work, since how many years? Do you feel rested when you wake up in the morning? YesNo Have you been diagnosed with Obstructive Sleep Apnoea (OSA)? YesNoDon't know If you have OSA, what treatment are you on? Weight LossCPAP deviceMouthpieceSurgeryOtherNo treatment "Sitting Disease" Score Please use the link below to assess your risk from continuous sitting. Please calculate your Sitting Risk Score "Sitting Disease"Risk. LOW risk indicates sitting less than 4 hours per dayMEDIUM risk indicates sitting 4 to 8 hours per dayHIGH risk indicates sitting 8 to 11 hours per dayVERY HIGH risk indicates sitting more than 11 hours per day FOR WOMEN ONLY Date of Last Menstrual Cycle -Month -DayYearDate Picker Icon How regular are/were your menses? What is/was your average days of flow? Do/did you have PMS, painful periods or other symptoms? If so, explain. Pregnancies (if any) MiscarriageChildrenVaginal DeliveryCaesarean Section Any pregnancy complications? Pregnancy diabetes (GDM)Pregnancy High Blood PressureHypothyroidism during pregnancyAny other condition Are you pregnant now? (If you are pregnant,then this program is not meant for you) YesNo Are you menopausal? YesNo If menopausal, since how many years? Did you have a hysterectomy with or without removal of one or both ovaries?* YesNo If you had a hysterectomy, how old were you then? Are you using hormone therapy?* YesNo If you are using Hormone Therapy, please list the names of the medications and state whether oral or transdermal. Are you taking any hormonal supportive herbs? If so, please list: Have you or do you experience any yeast infections or urinary tract infections? Please explain: Have you/do you still take birth control pills: If so, please list length of time and type. Have you had any problems with conception or pregnancy? Please explain: FOR MEN ONLY Erectile dysfunction is an important marker of your risk for diabetes, heart disease, stroke and dementia. What is your number?* 1234 MENTAL HEALTH STATUS Describe your mood and general disposition: Do you experience more than you would like of anxiety, depression or anger? YesNo On a scale of 1-10, one being the worst and 10 being the best, how would you rate your daily level of energy? Please explain:* 1 2 3 4 5 6 7 8 9 10 Worst Best 1 is Worst, 10 is Best At what point in your life did you feel best? Why? FAMILY HISTORY (Mother, Father ,Brother ,Sister, Children ,Grandparents, Others) Does anyone in your immediate family have any of the conditions listed below? CancerHeart DiseaseHypertension (High BP)ObesityDiabetesStrokeAutoimmune DiseaseArthritisKidney DiseaseThyroid problemsSeizures/epilepsyAnxietyDepressionScheizophreniaBipolar DisorderAsthmaAllergiesEczemaADHDAutismDementiaGenetic DisorderSubstanceOther If you have selected any of the answers above, please describe OTHER Please describe any other information you think would be useful in helping to address your health concern(s): HEALTH GOALS AND ASPIRATIONS Three months from today what changes in your health would you like to experience? Please describe. 3 Measurable Goals : (For example "I would like to weigh xyz kilograms" or "I would like to wear size M clothes" or "I would like to improve my marathon time by xyz minutes" ) Please list your thoughts and reasons why you want to achieve this for yourself: DISCLAIMER I understand that Dr.Shabnam Das Kar holds a medical license which is valid in India. I understand that I will consult with her through secure video conferencing. I agree to be under the care of a fully qualified medical doctor as my primary healthcare provider. Additionally, I also agree to keep Dr.Kar updated about my medical condition if and when anything changes. * I agreeI disagree Submit Dr. Kar sends weekly emails featuring health information. Your email address will be automatically added to the list. You may unsubscribe at any time. Should be Empty: