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Feedback FormDr. Nitin Gupte2017-05-19T13:42:06+05:30

Tell Us About Yourself

1 Personal Information

2 Diet Information

Name*
First Last
Age
Sex*
Height
Weight
Address
City / Town*
Phone No.*
Email*
Occupation

Complaints :
History Of Major Illness
Family History Of Major Illness
Present Diet Pattern :
Tea (cups)
Sugar (Tea Spoon Per Cup Of Tea)
Amount Of Milk (Per Cup Of Tea )
{For Example 1/3 Cup, 3/4 Cup, etc.}
Coffee (cups)
Sugar (Tea Spoon per Cup Of Coffee)
Amount Of Milk (Per Cup Of Coffee)
Milk (cups)
Type Of Milk
Mention Whether The Milk Is Whole, Skimmed Or Partly Skimmed
Sugar (Tea Spoon Per Cup Of Milk)
Breakfast
Breakfast: Mention As: One Egg / Two Slices Of Bread / Pohe One Bowl / Upama One Bowl / Two Idlis, etc.
Lunch
Mention As: Chapatis 2, Or Bhakri 1, Rice 1 Bowl, Curry One Bowl, Vegetables 1 Bowl, Green Salad Half A Bowl, etc.
Evening Snacks
Dinner
The Bowl Mentioned Above Should Be A Steel 'Wati' / 'Katori' Of 3 inch Diameter, 1.25 inch Height And Should Have reasonably Parallel Walls.
Find Out The Exact Number Of Chapatis And Bhakris Of Your Regular Size And Thickness Those Can Be Made From 100 gm Flour. Mention The Number Below.
Chapatis*
Bhakris*
Mention The Following In Tea Spoons Or Table Spoons Consumed By You Per Day :
1.Oil
Measuring Spoon
- Table Spoon
- Tea Spoon
2.Ghee
Measuring Spoon
- Table Spoon
- Tea Spoon
3.Sugar
Measuring Spoon
- Table Spoon
- Tea Spoon
4.Jaggery
Measuring Spoon
- Table Spoon
- Tea Spoon
5.Groundnuts
Measuring Spoon
- Table Spoon
- Tea Spoon
6.Coconut
Measuring Spoon
- Table Spoon
- Tea Spoon
7.Butter
Measuring Spoon
- Table Spoon
- Tea Spoon
Mention Curds, Butter Milk (In Cups), Fruits, Frequency Of Leafy Vegetables, Names Of Vegetables Generally Eaten, Frequency Of Non-veg Food And Alcoholic Drinks
Details
Mention below Other Details Regarding Your Health, Fitness, Life Style And Exercise If Any.
Other Details
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Address

Dr. Nitin Gupte Slimming and Wellness Clinic
47/22, Ekta Park, Above Nirmitee Show Rooms,
Law College Road, Pune, India, 411004

Mobile: +91 9890801727

E-mail:
slim@drnitingupte.com
drnitingupte@gmail.com

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Dr Nitin Gupte Slimming And Wellness Clinic

Home
About us
Testimonials
Doctors Recommend Us
Science of Slimming
Our Programs
- Distance Program
- PCOD Treatment In Pune
Our Results
Feedback Form
Contact Us