CLIENT FORM FOR SHARAN CONSULTATIONS

Consultation Package 3 months

Consultation Date : 15/12/19
Fees received: 7800/-

Name: Jethin
Gender:
Address:.
Phone No:
Email:
Date of Birth: 20/11/1984
Age: 35
Height: 173
Weight: 89.7 fat – 33.1%
Referred by: UC

CURRENT SITUATION
List your current problems and how long you have had them. Start with the oldest
problem and go to the latest one.

1 fatigue
2. Bloated
3. Thyroid
4. Fatty liver
5.
6.
7.
8.
9.
10.

CURRENT MEDICATIONS
List all the medications and supplements being taken in detail. Please list every
individual dose as a separate medication. Please list every supplement and topical
ointments or applications and even oral contraceptives in details.

Medication For what Dosage At what Since Any problems

taken (mg, ml, time approximately with this
etc.) how long medication?
Thyrtonorm Thyroid 88 mg 5 years

S.No Questions Reply

1 Are you under any other kind of therapy or None
treatment besides medicines?
2 Any major past health problems or surgeries? None
3 Any major allergies or food aggravations? None
4 Any emergency treatments that you have None
needed in the past? Please specify.
5 Any hospitalization needed in the past? For what Jaundice 7- 8 years
condition?
6 Do you do any exercise regularly ? Twice a weel

7 Do you have any major stress? Yes

Do you have any major habits or addictions ? Twice a week
8 (tea, coffee, smoking, alcohol, drugs, anything
else?)
FAMILY HISTORY
S.no RELATIONSHIP
1. Mother BP
2. Father Diabetes
3.
4.
Please list all the foods you normally take, listing all options so as to give a fair idea of your daily
diet. Do not miss out the teas and coffees. Try to list everything. Details will enable your
therapist to give you a diet plan as close to what you are used to and like as possible

DAILY MEAL PLAN

Food options TIME
1. Breakfast – poha, paratha, roti + veg, cornflax + 12- 1.00 pm
milk
2. Lunch- rice+ roti/ paneer/ 4-5 .00 pm
3. Snack- tea+ biscuits/ sandwich / peanuts/
 haldiram
4. Dinner- rice / roti+ same like lunch
5.
6.
7.
8.
10
11
12.
13.
Scan Laboratory Tests
Attached with this form