Your Full Name

Your Age

Gender

Female

Male

Others

Contact Information:

Email Address

Mobile Number

Physical Parameters:

Height (in feet)

Example: If you're 5 feet 6 inches, enter 5.6

Weight (in kg)

Example: If you're 55 and half Kg, enter 55.5

Systolic Blood Pressure

Enter your systolic BP if you know.

Diastolic Blood Pressure

Enter your diastolic BP if you know.

Section 1: Your Current Medical Condition

Enter your chief medical concern (Enter what is most concerning OR specify no concerns)

Do you have any pre-existing medical conditions? (Select all that apply)

Obesity

Diabetes

Osteoporosis

Hormonal Imbalance (PCOS, Thyroid, etc.)

Severe Period Cramps

Post-Menopausal Issues

None

Have you ever been diagnosed with any of the following conditions?(Select all that apply)

High Blood Pressure

High Cholesterol

Autoimmune Disorders

Cancer (Current or Past)

None

Do you have a family history of cancer (especially cervical, breast, ovarian, or prostate cancer)?

Section 2: Lifestyle, Diet & Risk Factors

Do you smoke or consume tobacco in any form?

Do you consume alcohol?

Regularly

Occasionally

Do you follow a regular exercise routine?

Yes, daily

Occasionally

No, not regularly

Do you often experience work-related stress or tension?

Never

Rarely

Sometimes

Often

Almost Always

How would you describe your energy levels by the end of the day?

Very High - I feel active and energetic

Moderate - I feel slightly tired but manageable

Low - I feel drained and fatigued

Very Low - I struggle to continue daily tasks

Do you have trouble getting sound sleep at night?

Never

Rarely

Sometimes

Often

Almost Always

How refreshed do you feel when you wake up in the morning?

Very Refreshed - Energetic and ready to go

Moderately Refreshed - Slightly rested but not fully energetic

Not Refreshed - Still tired or groggy

Very Tired - Feel exhausted even after sleeping

How would you describe your diet?

Balanced (includes fruits, vegetables, proteins)

High in processed/junk food

Vegetarian

Vegan

Non-Vegetarian (Includes lean meat like chicken and fish)

Non-Vegetarian (Includes red meat frequently)

What are your staple dietary preferences? (Select all that apply)

Do you follow a specific regional or cultural diet style?

North Indian

South Indian

Gujarati

Marathi

Goan

Mangalorean

East Indian

Others

No specific preference

How do you usually plan your meals?

I manage my meals personally, so you can recommend an individual diet plan

I prefer a family-inclusive plan that suits everyones meals at home

Free Health Assessment

Understanding your current health status helps you identify potential risks, personalize your consultation, and ensure safe and effective wellness recommendations.

Personal Details:

Contact Information:

Physical Parameters:

Section 1: Your Current Medical Condition

Enter your chief medical concern (Enter what is most concerning OR specify no concerns)

Do you have any pre-existing medical conditions? (Select all that apply)

Have you ever been diagnosed with any of the following conditions?(Select all that apply)

Do you have a family history of cancer (especially cervical, breast, ovarian, or prostate cancer)?

Section 2: Lifestyle, Diet & Risk Factors

Do you smoke or consume tobacco in any form?

Do you consume alcohol?

Do you follow a regular exercise routine?

Do you often experience work-related stress or tension?

How would you describe your energy levels by the end of the day?

Do you have trouble getting sound sleep at night?

How refreshed do you feel when you wake up in the morning?

How would you describe your diet?

What are your staple dietary preferences? (Select all that apply)

Do you follow a specific regional or cultural diet style?

How do you usually plan your meals?

Do you experience frequent digestive issues, bloating, or gut health problems?

Section 3: Menstrual & Reproductive Health (For Women Only)

Do you experience irregular periods or severe menstrual cramps?

Have you been diagnosed with PCOS, endometriosis, or any reproductive health issues?

Are you currently undergoing any hormone therapy or using birth control pills?

Have you received an HPV vaccine?

Section 4: Side Effects & Precautions Awareness

Do you have any known allergies to supplements, herbs, or medications?

Are you currently on any long-term medications? (e.g., blood thinners, insulin, steroids, antidepressants etc.)

Do you have kidney or liver-related conditions that may require dosage adjustments?