S.No.

_____________ Date:_____________
Nutritional Assessment
(Protein & Mcro Nutrients)
To help assess and prevent lifestyle diseases like Heart Disease, Osteoporosis, Cancer, Diabetes etc.

Name:______________________________ Age:______________Height:_____________________

Weight:___________ Sex: Male / Female

Address:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Mobile Number:_______________________

Category: Adult / Child /Pregnant or Lactating Mother/ ody Builder/ Heavy Exerciser

Protein Gms/
Standard Serving* Food
Meal of the Day Serving Size (gms) Taken Protein Intake Remarks/ Recommendation
Break Fast
Egg 57 g 7.0
3 Bread Slices 50 g 4.4
Roti 35 g 3.0
Dosa 50 g 2.1
2 Idlys 75 g 2.1
Milk 200 ml 7.0
Parantha 50 g 4.1
Puri 25 g 2.0
Rice Flakes 100 g 6.6
Rice Puffed 100 g 7.5
Semolina 50 g 5.2
Lunch
Salad Nil
Roti 35 g 3.0
Rice 125 g 2.8
Dal 75 g 3.0
Sambhar 100 g 2.1
Vegetable Nil
Fish 50 g 8.8
Curd 75 g 2.6
Curhi 100 g 3.1
Khichri 100 g 4.3
Dinner
Roti 35 g 3.0
Rice 125 g 2.8
Dal 75 g 3.0
Sambhar 100 g 2.1
Vegetable Nil
Chicken/ Mutton 1 pc 8.0
Chholey 100 g 4.2

Total protein requirement as per Indian Council of Medical research (ICMR) (1gm/KG/body wt.)- _______________________

Total protein intake per day -______________________________________________________________________________

Protein supplementation required - _________________________________________________________________________

Recommended servings of fresh fruits and vegetables taken per day - ____________________________________________

Total Number of fresh fruits and vegetables taken per day - _____________________________________________________

Natural Multivitamin & Multimineral Required- ________________________________________________________________

 Wellness Solutions
NEUTRACEUTICAL
Yes No PROTEIN INTAKE RECOMMENDATIONS
Is your protein intake less than the ICMR RECOMMENDATIONS. [ (Adult 1.0 g), (Child 1.5 g), If you answered YES to any or both the
(Pregnant / Lactating Mother 1.75 g), (Heavy Exercise Oriented 2.0 g) per kg body weight per statement, you may benefit from Protein
day? Powder supplement to fill in the
nutritional gap.
Is you protein intake primarily from ANIMAL SOURCES (non-veg & diary products which are
also rich in fats and cholestrol) and do you want to SUBSTITUTE it with a plant based product
which is high protein, low fat and a zero cholestrol source ?
NEUTRACEUTICAL
Yes No NUTRITIONAL INTAKE RECOMMENDATIONS
Do you often SKIP meals? If you answered YES to 2 or more of the
Do you often reduce CALORIE INTAKE to try and lose weight? statements, you may benefit from taking
Do you Not eat fruits and vegetables of different colours on most days? a Neutraceutical
MULTIVITAMIN/MINERAL Supplement
Do you often eat less than six servings of WHOLE GRAINS such as whole wheat bread, cereal,
with ANTIOXIDANTS - VITAMIN-C to fill
rice each day (same for adolscents, lesser for younger kids). One serving = 1 chapati/
your/ your family or your kids nutritional
slice bread, 1/2 cup rice/ cereal etc ?
gap DAILY.
Do you often eat the same foods every day without thinking about whether you are eating a
BALANCED DIET?
Do you eat "FAST FOODS" or convenience style foods that are high in FAT CONTENT (samosa
, anything deep fried etc) three or more times a week?
Do you eat SNACKS with low nutritional content (sodas, chips, sweets, processed foods )
almost every day?
NEUTRACEUTICAL
Yes No KIDS ENERGY LEVEL RECOMMENDATIONS
Is the childs daily SCHEDULE very demanding physically/ mentally? If you answered YES to any or both the
statements, the child may benefit from
Does your child come back from school completely TIRED with no energy left to study or play? taking KIDS Neutraceutical
MULTIVITAMIN for KIDS and PROTEIN
NEUTRACEUTICAL
Yes No LIFE STYLE RECOMMENDATIONS
Do you SMOKE or often breathe other people's smoke? If you anwered YES to 3 or more of the
Do you live in an URBAN or highly POPULATED area? statements, you may benefit from taking
Your place of work or the way to work - Is it highly POLLUTED ? a Neutraceutical VITAMIN-C product,
Do you EXERCISE less than for 1 hour daily or atleast 3 days in a week? and a SELENIUM with VITAMIN-E
product to meet your antioxidant needs
Are you exposed to a lot of SUNLIGHT, i.e - more thaan one hour of mid day sun several times
or a Neutraceutical MUTIVITAMIN with
a week?
ANTIOXIDANTS DAILY.
Do you consume ALCOHOL?
Do you consume fried, fatty or processed FOODS three or more times a week?

Do you normally eat less than 5 servings of different FRUITS & VEGETABLES each day. (One
Serving = 1 medium fruit, 1/2 cup cooked vegetables, 3/4 cup juice, 1 cup raw vegetables) ?
Do you suffer from a family history of LIFE STYLE DISEASES such as Diabetes, Heart Attach,
Stroke, Cancer, Asthma ?
Do you have STRESS in your life?
NEUTRACEUTICAL
Yes No ADULT ENERGY LEVEL RECOMMENDATIONS
Do you often find yourself lacking ENERGY during the day?
If you answered YES to any statement,
you may benefit from keeping a
Do you find it difficult to cope with the physical and mental effects of STRESS in your daily life? SIBERIAN GINSENG with GINKO
Do you want to enhance your ENERGY LEVEL for an important physically or mentally BILOBA and taking it when needed, to
demanding event at Office, Play Ground/ Sport and / or at Home? meet your individual needs.
NEUTRACEUTICAL
Yes No IMMUNITY - NATURAL DEFENSE SYSTEM RECOMMENDATIONS
Are you prone to FALLING ILL due to change in WEATHER CONDITIONS and un expected If you anwered YES to 1 or more
exposure to rain, cold, dust, pollution etc.? statements, you may benefit from taking
Are you prone to falling ill due to spreading of an INFECTIOUS disease? ECHINACEA.
Are your prone to falling ill during an IMPORTANT EVENTS (exams, interviews, important travel,
important event of the week, due to anxiety etc ?
NEUTRACEUTICAL
Yes No WOMAN'S HEALTH RECOMMENDATIONS
Are you a women of CHILD BEARING AGE, and thinking about having a baby? If you anwered YES to 2 or more of the
Are you pregnant, or a NURSING MOTHER? statements, you may benefit from taking
Do you consume green LEAFY VEGETABLES less than 3 times a week? a IRON FOLIC product and a CALCIUM-
Do you often/ frequently feel TIRED and get EXHAUSTED easily? MAGNECIUM supplement.
Are you an ADOLSCENT/ a young girl?
Are you a complete VEGETARIAN?
NEUTRACEUTICAL
Yes No BONE HEALTH RECOMMENDATIONS
Does your exercise routine regularly include WEIGHT BEARING ACTIVITIES (such as If you answered YES to 2 or more of the
weightlifting or other resistance exercises), atleast twice a week? statement, you may benefit from taking a
Does your daily routine regularly include WEIGHT BEARING ACTIVITIES including self weight, GLUCOSAMINE HCL with SOYA
in turn causing STRAIN- when walking or while standing upright during the course of the day - is PROTEIN ISOLATE to meet your
the pain experienced atleast twice a week? individual needs.
Are you concerned about OSTEOPOROSIS ( for example a famaily history, alow calcium diet,
small bone structure etc.) ?
Do you or any one in your immediate family/ surrounding/ colleagues SMOKE?
Do you drink more than 2 cups of COFFEE or TEA in a day?
Are you hypertensive - HIGH BLOOD PRESURE?
Do you frequently get LEG CRAMPS?
Do you regularly feel PAIN or STIFFNESS in the JOINTS?
NEUTRACEUTICAL
Yes No JOINTS HEALTH RECOMMENDATIONS
Are you over 35 years? If you anwered YES to 1 or more of the
Do you experience a mild stiffness or pain in the joints - in the morning or as and when you get statements, you may benefit from taking
up from a seat after sitting in a for some time at office or at home? a GLUCOSAMINE HCL and CALCIUM
Do you suffer from or are you concerned about OSTOEARTHRITIS (for example, due to family MAGNESIUM with SOYA PROTEIN
history, poor or compromising work posture etc.) ? ISOLATE to meet your individual needs.
Are your joints over burdened due to your weight/ intensive sports/ work/ other reasons?