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Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)



Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST

Date:

Personal Information
Name
Age
Height (cms):
Weight (kgs):
Home Address
Tel No
E-mail Address:




______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
Medical History
Diabetes
Yes / No
Yes if on treatment with diet/ medicines/ Insulin
High blood pressure
Yes / No
Systolic BP >140 mm Hg / Diastolic BP >90 mm Hg on medicines

High cholesterol / triglyceride /
Uric acid levels
Yes / No
Give the values
Hypothyroidism Yes / No
Current medications Yes / No





______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
Lifestyle Factors

Smoking Ex-smoker / current smoker / never smoked
If current smoker, Number of cigarettes smoked / day
Substance Abuse : Tobacco / others : Yes / No, If yes, daily / occasionally
Alcohol consumption Yes / No.
If yes, How many times in a week?
How many drinks?
What do you munch with the drinks?
Occupation Sedentary / physically active job




______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
Family History
Heart attack / stroke / sudden death Father / Mother / Siblings
Diabetes Mellitus Father / Mother / Siblings
High blood pressure Father / Mother / Siblings
Obesity Father / Mother / Siblings
High cholesterol / lipid levels Father / Mother / Siblings




______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
Dietary History:
Write in terms of cups/ katoris & teaspoons / tablespoons. Specify the quantities of chapattis / idlis etc
Early morning: Fill in details
Breakfast: Fill in details
Mid-morning: Fill in details
Lunch: Fill in details
Tea: Fill in details
Mid-evening: Fill in details
Dinner: Fill in details
Bed-time: Fill in details


Items Number Of Times A Week
Non-vegetarian food
Eggs (number)
Cake and pastries
Snacks
Chocolates
Aerated drinks


______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
Ice creams
Fruits
Fruit juices
Indian sweets
Fried foods
Salads






Exercise

Do you exercise: Yes / No

USE OF HIGH AVERAGE LOW
Oil
Ghee
Butter
Coconut
Groundnut
How much oil are you using in a
month?

Number of family members:
Type of oil


______________ _________________________________________________________________________

Cumballa Hill Hospital (10 am - 1 pm Tue / Thur /Sat)

Clinic: 11 A Satguru, 16 French Bridge, Off Hughes Road, Mumbai 400007. Maharashtra. India
Consultation Timings: 11 - 7 pm Mon to Fri Ph: 2364 5330 / 2368 5319 Email: desai_niti@hotmail.com
NITI DESAI
MSc SRD (UK)
CONSULTANT NUTRITIONNIST
How many times in a week?
Do you walk / jog / use a treadmill / cycle / swim / workout in the gym or describe any
other activity.

How long is your session?