Section 1: General Information
Name:                                          Maliha
 Age:                                           21
 Gender:                                        Female
 Contact Information:                           0324896967
 Date of Assessment:                            7 jan 2025
Section 2: Anthropometric Data
 What is your current weight and height? (Self- 52, 5’3
 reported or measured)
 Have you experienced any significant weight Yes
 changes in the past 6 months?
        If yes: How much weight was gained
         or lost? Over what period?
 What is your usual weight?                     50
 Do you have any concerns about your weight Yes
 or body composition?
Section 3: Dietary Intake
  Could you describe a typical day of eating for Meals
 you (meals, snacks, and beverages)?
 How many meals do you usually eat per day? 2, yes
 Do you snack between meals?
 How often do you eat out, and where do you Daily, mix
 typically go?
 Do you follow any specific diet plan (e.g., No
 vegetarian, vegan, keto, intermittent fasting)?
   Are there any foods or food groups you Yes
 avoid? Why?
 How much water do you drink daily? (In liters 5 cups
 or cups)
 Do you consume any of the following Soda
 regularly:
           o   Alcohol
           o   Caffeinated beverages (e.g.,
               coffee, tea, energy drinks)
           o   Sugary beverages (e.g., soda,
               juices)
Section 4: Food Preferences and Accessibility
 Do you have any diagnosed medical conditions No
 (e.g., diabetes, hypertension, heart disease)?
 Are you currently taking any medications or No
 supplements?
       If yes: Please specify.
 Have you experienced any of the following Yes
 recently:
       Digestive issues (e.g., bloating,
        constipation, diarrhea)
       Fatigue or low energy
       Loss of appetite or changes in hunger
 Do you have any food allergies or intolerances? Yes
Section 6: Physical Activity
 How often do you engage in physical activity?   No
       Type: (e.g., walking, gym, yoga)
       Duration:
       Intensity: (light, moderate, vigorous)
 Has your level of physical activity changed No
 recently?
     1. Do you have any physical limitations No
         affecting your ability to exercise?
Section 7: Lifestyle and Behavioral Factors
 What is your occupation, and does it affect Student, yes
 your eating habits?
 Do you have a regular sleep schedule? How 9-10 hours
 many hours do you typically sleep per night?
 How would you describe your stress levels?   No stress
       If high: Do you feel it affects your
        eating habits?
 Do you smoke or use tobacco products?           No
Section 8: Goals and Concerns
 What are your primary reasons for seeking General health, weight management
 nutritional assessment?
       Weight management
       Medical condition
       Athletic performance
       General health
       Other: _______
 What are your short-term and long-term health Weight management
 goals?
Do you have any specific concerns about your No
current diet or health?