Personal Information Form – Diet Chemistry

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Informed Consent Form & Terms for Nutritional Counseling

I Miss/Mrs./Mr./Master/Dr.

give consent to DIET CHEMISTRY (Gurleen Kaur) to provide Nutrition counselling to myself or the client for which I am legally responsible. In any of the condition. MONEY WILL NOT BE REFUNDED. IF ANY MEDICAL CONDITION KINDLY PROVIDE WITH REPORTS AND PRESCRIPTION OF THE DOCTOR. (In any of the stage you can only freeze or transfer your package). Your opted package is ONLY VALID for 1 month extra. After that grace period your package will DISCONTINUE.

Name Mr/Miss/Mrs/Dr *

Age *

Sex *

Height *

Weight *

Phone Number *

Address *

Email ID *

Medical History

Buisness/Job/Homemaker

Business/Job Type

Surgery

Constipation/Acidity/Bloating

Menstaration Cycle

Stress/ Anxiety/ Depression

Blood Report

Nutritional Deficiencies

Food Allergy

Food Timings

Food Addictions

Food Dislikes

Veg/Non-veg

Water Intake

Aerated Drinks

Workout/ No. of steps

Outings/Meals from outside

Cheat Day

Followed Diet Plan Before, If Yes, when and from whom

Wake up time

Sleep time

Workout/ Excercise Time

If working, Time when leave for work

If working, Time when reach home

If working, Lunch time

Any other information to be added

Package opted

Reference Name/Relation

I agree to all above mentioned conditions.

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