KYC FORM

    SECTION 1: Personal Details

    Full Name:

    Age:

    Gender: MaleFemaleOther

    Contact Number:

    Email ID:

    Address:

    Occupation:

    Referred By:

    SECTION 2: General Health Concerns

    Overweight / ObesityHormonal imbalance / PCOD / MenopauseIVF / Pregnancy / LactationGut issues (Acidity / IBS / IBD / Constipation)Autoimmune disorderLow energy / FatigueFrequent body painsHair fall / DandruffCravings (Sugar / Salt / Carbs / Fried)Sleep disturbances / InsomniaHigh stress / AnxietySkin issues (Acne / Pigmentation)Irregular menstrual cyclesMood swingsBloating / GasMigraine / Frequent Headaches

    SECTION 3: Medical History

    Gut-Related Issues

    Acidity / GERDBloatingGasConstipationIBSIBD

    Hormonal Disorders

    Thyroid Disorder (Hypo / Hyper)PCOD / PCOSPerimenopause / MenopauseIrregular CyclesIVF / Infertility

    Autoimmune Conditions

    Hashimoto’sPsoriasisRheumatoid ArthritisAnkylosing SpondylitisCeliac DiseaseLupus (SLE)

    Others:

    Other Medical Conditions

    Diabetes (Type 1 / Type 2 / Gestational)High BPHigh CholesterolAnemiaAsthma / AllergiesKidney / Liver DisordersHeart DiseaseDepression / AnxietyMigraine

    Current Medications / Supplements:

    Past Surgeries / Treatments:

    SECTION 4: Body Composition Analysis

    Height (cm):

    Weight (kg):

    BMI:

    Body Fat %:

    Visceral Fat:

    Muscle Mass:

    Metabolic Age:

    Waist (inches):

    Hip (inches):

    Waist-Hip Ratio:

    SECTION 5: Lifestyle Assessment

    1. Physical Activity Level

    Sedentary (No activity)Light (1–2 days/week)Moderate (3 days/week)Active (5 days/week)Very Active (Daily / 7 days)

    Activity Type

    WalkingGymYogaDanceSports

    Other:

    2. Sleep Quality

    Sleep Duration: hours

    RestfulLight / DisturbedInsomnia / Difficulty sleepingDaytime drowsiness

    3. Stress Level

    LowModerateHigh

    Trigger Areas:

    4. Bowel Movements

    RegularConstipationLoose StoolsGas / Bloating

    5. Water Intake: Litres/day

    6. Tea/Coffee Consumption

    Tea: cups/day

    Coffee: cups/day

    SECTION 6: 24-Hour Diet Recall

    Time

    Meal

    Food Item

    Morning

    Breakfast

    Mid-morning

    Lunch

    Evening

    Dinner

    Post-dinner

    SECTION 7: Symptom & Wellness Tracker

    Energy Levels

    HighModerateLowExhausted even after rest

    Hair & Skin

    Hair fallDull hairDandruffDry skinAcne / Pigmentation

    Cravings

    SugarFriedSaltTea/CoffeeCarbs (Bread/Pasta/Rice)Chocolates

    Body Pains

    Neck / BackJointsMuscle WeaknessGeneral Aches

    SECTION 8: Lab Reports Checklist

    CBCThyroid Profile (TSH, T3, T4)HbA1c / Fasting / PP SugarInsulin (Fasting / Post-Meal)Lipid ProfileLiver Function Test (LFT)Kidney Function Test (KFT)Vitamin DVitamin B12Iron Panel (Iron, Ferritin, TIBC)Hormonal Panel (FSH, LH, AMH, Prolactin, Testosterone, DHEA-S)CRP / ESRPSA (For Males)ANA / Autoimmune PanelStool Test

    Other:

    Date of last blood test:

    SECTION 9: Goals & Expectations

    Weight LossEnergy BoostHormone BalanceBetter SleepImprove DigestionHair/Skin HealthReduce InflammationStress ReliefDisease Management

    If Disease Management, specify:

    Declaration

    I confirm the above information is true and authorize the use of my data for personalized nutrition planning.

    Signature:

    Date: