Consultation – Khairo Diet Clinic

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Age

Waist Line

Height

Weight

BMI

Ideal Weight

Past Medical History

Recent Medical Diagnosis

Family History

Present Medications

Physical Activity Level

Ever Tried Losing Weight? (If Yes, how many kgs)

Ever Seen a Dietitian?

Past Fitness History

Gestational Age (If Applicable)

Diet History (Food Likes/Dislikes/Allergies)

24 Hour Dietary Recall

Nutritional Diagnosis

Plan

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Summary