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Health and Lifestyle
1.
What do you usually have for breakfast?
Carbohydrate based?
No Breakfast?
So called modern Breakfast?
Other (please specify)
2.
How many cups of tea/ coffee do you usually have during the day?
1-3
3-6
More than 6 cups
3.
Do you have fatty liver/ a big Belly
Yes
No
4.
Do you suffer from Digestive Health issues like Gastric or constipation?
Yes
No
*
5.
Do you suffer from lifestyle diseases like
(Required.)
Diabetes
Heart disease
Joint pain
Blood pressure
Gynecological issues
Sexual health
Other (please specify)
6.
What do you think What is the main cause of your health problem?
Your lifestyle
Your food habits
Don't take care of yourself
Other (please specify)
7.
Would you be interested to improve your health with better nutritional habits?
Yes
No
8.
How many kgs of weight do you want to lose?
5-10 Kgs
10-20 Kgs
20 Kgs and above
Other (please specify)
*
9.
Do you want to improve your skin health?
(Required.)
Yes
No
*
10.
Name and contact details.
(Required.)