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Information Sheet

Hello dears, we are glad to serve you better by filling the following questionnaire, as it will help us collect information so that we are aware and knowledgeable of the programs that will be directed to you.

    Age /
    Name /
    Weight /
    Job /
    Height /
    Waist circumference /
    Hip circumference /
    Medical problems or chronic diseases /
    Is obesity started early in childhood?
    If you answer with yes, please tell more details
    please write names of medications,
    intake time and doses /
    Medications /
    Highest weight you reached /
    Lowest weight you reached /
    Kind or name of diet you followed /
    Date of last time you followed diet /
    please tell more details /
    Date of last medical lab investigations /
    Non preferred food /
    Preferred food /
    Number of meals per day /
    Number of snacks per day /
    Timing of taking meals /
    Timing of taking snacks /
    Your Goals /
    Daily activity level /
    Low - Medium - High
    Region of accumulated fats /

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