Follow Up Form - 9 Week Class

THE HEALTH AWARENESS CENTRE
THE HEALTH AWARENESS CENTRE

Follow Up Form - 9 Week Class
Please note that this is a multiple page form. There is a SAVE button at the end of each page. Ensure that you save the form before going to the next page. If it prompts to Login, ignore and click "Skip Create an Account" at the bottom of the pop-up.
This Form is best suited to be filled on a laptop/desktop, rather than on a mobile.

Before you start:
- Sit in a calm and undisturbed environment.
- Take your time to fill in the Form.
- Reflect on the questions. Give it some thought before you begin writing.
- Consider this as an opportunity to reflect on where you are and which direction you wish to go.
- This form is as much for you as it is for us the THAC Team.
Counsellor Inputs
History/ Symptoms
(taken by the Counsellor during the appointment)
Personality
medically oriented, open to change, loves her, tea..etc.
Focus Points for the Team
HE Inputs
FU Call by HE
Date & Comments
Comment by Deactivation Team
Date & Comments
Parameters to be Monitored
FU by Counsellor
Comment by Counsellor after FU call
Areas to focus on for the Team
Files to be uploaded

Browse Files

Cancelof
PERSONAL DETAILS
Date*

DayMonthYear
Date
Name*

First NameLast Name
Age*
Weight (kg)*
Height*
Occupation*
SingleMarried
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
State*
Country code*
Contact Number*
WhatsApp Number*
Email*
Which year did you attend the 9 Week Nutrition Re-Education Classes?*
Are you part of the Class WhatsApp group?*
Have you read all the material handed out during the 9 Week Nutrition Re-Education Classes? Do you have any clarifications on it?*
What are your new interests / hobbies post the 9 Week Class?*
What is your opinion about your health after the 9 Week Class?*

PERSONAL ASSESSMENT
(A) DIETARY HISTORY
VegetarianNon-Vegetarian
If Non-Vegetarian how many times a week
Time of Breakfast*
Time
Breakfast*
ITEMS AND QUANTITIES (eg 1 glass milk, 2 slices toast)
Time of Lunch*
Time
Lunch*
ITEMS AND QUANTITIES
Time of Snack*
Time
Snack*
ITEMS AND QUANTITIES
Time of Dinner*
Time
Dinner*
ITEMS AND QUANTITIES
Time of In-between Eating*
Time
Items & Quantity*
Biscuits, Chips, Haldi water, Kadha, Giloy etc.

Write the quantity you consume of the following items. (eg: Tea- 3 cups daily, Aerated- twice a week, Alcohol- 6 pegs monthly)*

Rows	Daily	Weekly	Monthly
Tea / Coffee
Milk / Milk products
Energy Drinks / Protein Shake
Non-veg Food
Bread/Biscuits/Bakery Products
Wheat Products
Sugar / Sweets / Chocolate
Deep-fried Food
Oil for cooking
Iodized salt
Alcohol
Water
Tobacco / Smoking

Write the quantity you consume of the following items.*

Rows	Daily	Weekly
Fruit
Fruit juice
Vegetable juice
Salad
Sprouts
Nuts
Dates / dry fruits
Lemon

What do you now do when you Eat out at parties, restaurants, social functions?*
How do you balance your food when you are traveling?*
When you are in Stress do you make any changes to your Food Routine?*
Is there a change in your Craving? What do you Crave for now?*

Have your ailments increased or decreased after the 9 Week Nutrition Re-Education Classes?*
Have you had cold, fever, diarrhea, skin rash after the 9 Week Nutrition Re-Education Classes?*
What kind of attention/ treatment do you give it now? Include all natural remedies, therapies too if you take.*
What are the medications/supplements you are taking now?*
Has your medicine/supplements dosage decreased?*
EasyDifficultImpossibleNo change
How do you feel about your health now? Do you still have any fears?*
Other observations about your body, self esteem, energy levels.*
What is your current health goal?*

Is there anything else you would like to share with us?*
Energy Exchange*
prevnext( X )
Energy Exchange for the Counselling3,500.00INR

Subtotal 0.00INRTax 0.00INRTotal 0.00INR
CGST (9%)*
SGST (9%)*
IGST (18%)*
Should be Empty:

Rows	Regular	Sometimes	Not doing
Sunning
Positive thinking
Creative activities
Deep Breathing
Relaxation - Pausing between day
Sensory relaxation
Cooling down with rosewater eye patch
Lymphatic movements
Postural correction
Meditation / Gibberish / ‘M’ chanting
Aroma bath at bedtime
Electronic gadgets off 1 hr before bedtime

Rows	Fairly Easy	Moderately Difficult	Challenging
Kitchen management
Cooking methodology
Sourcing ingredients
Self Care daily practice
Family acceptance
Symptom management

THE HEALTH AWARENESS CENTRE

PERSONAL DETAILS

PERSONAL ASSESSMENT

(A) DIETARY HISTORY

(C) DAILY ROUTINE

OVERALL HEALTH PERSPECTIVE