RECALL AND APPOINTMENT BOOKING FORM

RECALL AND APPOINTMENT BOOKING FORM

Dietitian Shamika' s "Eat Healthy" Diet and Wellness Clinic
Name*

First NameLast Name
Email*
example@example.com
Phone Number *
Please enter a valid phone number. (Country code) followed by your Mobile No.
Your Age (Yrs)*
Your Gender*

MaleFemale
Your Height (In Cms)*
Your Weight (Kgs)*
BMI
Referred by

SelfDoctorFriends / Relatives
Name of Doctor
Why do you want Diet Consultation*

Overweight ( want to reduce weight)Underweight (want to increase weight)Due to any medical condition
In previous question if any medical condition is selected then kindly specify.
Kindly upload your recent Investigation Reports / Blood Reports.

JPEG or PDF
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Any other issues like

Excessive HairfallExcessive AcneHair on Face (For Females)Colour of Neck becoming BlackJoint pain / Knee painWeakness / Fatigue / TirednessTingling sensation in hands or legsAcidity / Bloating / ConstipationNone of AboveOther
Are you Vegetarian*

YesNoYes but can have eggs
Are you Allergic to anything ? If yes kindly specify.*
How frequently you have junk food / Outside food

FrequentlyTwice in a weekOnce in a weekOnce in 2 weeksOnce in a monthOther
Do you work in Shifts*

YesNo
If Yes then please mention your shift timings.
Do you have dislike to any particular food. If any kindly specify.
At what time do you have Breakfast ?*

Hour Minutes

AM/PM Option
What do you have for Breakfast ?*
Eg. Poha , Upma , Dosa Etc
At what time do you have Lunch ?*

Hour Minutes

AM/PM Option
What do you have for Lunch ?*
Kindly mention portion size for eg. 2 Chapati/Roti or 1 Bowl of Rice/ 1 Bowl of Sabji
At what time do you have Evening Snack ?

Hour Minutes

AM/PM Option
What do you have during Evening Snack ?
At what time do you have Dinner ?*

Hour Minutes

AM/PM Option
What do you have for Dinner ?*
Kindly mention portion size for eg. 2 Chapati/Roti or 1 Bowl of Rice/ 1 Bowl of Sabji
Do you Exercise ?*

Yes, DailyYes, 5 Days a weekYes, 3 Days a weekSometimesNeverOther
Nature of your Exercise ?*

Only Cardio ( walking , running etc)Weights TrainingMixture of both Cardio and WeightsHigh Intensity WorkoutsOther
Do you take any Nutritional Supplements?*

YesNoSometimes
Do you Smoke ?*

YesNo
Do you consume Alcohol ?*

DailyWeekly twiceWeekly onceOcassionallyDo not DrinkOther
What type of Consultation do you prefer*

Online / Telephonic Consultation (Rs 500)
Advance Payment to be done for confirmation of your Telephonic Appointment . ( Kindly take Screenshot of your payment for Uploading Later)*

Pay through scanning BarcodePay through UPI IDPay through credit card / debit card (extra taxes applicable)
Kindly use the UPI ID for payment of Rs 500/- : dietitianshamika@axisbank
Use the following link for payment through card: https://imjo.in/TDTug8

(Extra charges applicable)
Kindly upload screenshot of your payment receipt*

In JPEG or PDF
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Kindly schedule your Online / Telephonic Appointment
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